Customer Registration Form
The tests listed in our catalogue are
carefully developed assessment
instruments that require specialized
training to ensure appropriate use.
Eligibility to purchase these tests,
therefore, is restricted to individuals
with specific training and experience
in a relevant area of assessment.To
expedite the registration process, please
include copies of credentials (e.g.,
university transcripts, license or
certificate, membership card)
supporting the information below.To
purchase B-Level tests and materials,
you must have an advanced degree
from an accredited university and have
successfully completed courses in
interpretation of psychological tests
and measurement at an accredited
university.To purchase C-Level tests
and materials, you must fulfill all of the
qualifications required of B-Level test
purchasers plus possess an advanced
degree that provides supervised
experience in the administration and
interpretation of psychological tests.
Refer to “Qualification levels and
Qualifications for Test Purchase”
statements on page 153 of your
Psychological Catalogue or page 99 of
the Speech/OT Catalogue. Regardless
of use, however, all first-time
purchasers of A-, B-, and C-Level Tests
must complete this Form.
Please complete all the information included on this form as it is required for registration and purchasing of
assessment tests and related materials.
Name ______________________________________________ Daytime Phone __________________________ Fax _______________________
Organization/Company ________________________________________________________________________________
Shipping Address: Street________________________________________ City __________________ Prov. ________ Postal Code ____________
Profession __________________________________________________ Position/Title _______________________________________________
Language Preference English ■
French ■
E-Mail address _____________________________________
(Please provide e-mail address to ensure you receive timely product updates and enhancements.)
Type of Business
■ Clinic/Counselling Service
■ Human Resource
■ Social Agency
■ College/University
■ Government Agency
■ Private Practice
■ Rehabilitation Centre
■ Other ____________________________________
■ Hospital
■ School or School Board
Primary Area of Specialty (based on training, or supervised experience) check only one
■ Counselling
■ General Education
■ Neuropsychology
■ Physical Therapy
■ Psychology
■ School Psychology
■ Other (specify) ____________________________________
■ Occupational Therapy
■ Speech Language Therapy
Educational Background
■ Bachelor’s Degree:
■ Master’s Degree:
■ Doctorate:
■ Other:
Year
Year
Year
Year
___________
___________
___________
___________
Institution
Institution
Institution
Institution
___________________________________
___________________________________
___________________________________
___________________________________
Major
Major
Major
Major
__________________________
__________________________
__________________________
__________________________
Professional Credentials
■ Licensed (Province) ____________ Licensing Board _____________________
■ Licensed (Province) ____________ Licensing Board _____________________
Lic # ____________________ Exp ______________
Lic # ____________________ Exp ______________
Membership in Professional Organization(s) Status (check as many as apply)
■ CAOT
■ OPA
■ CARP
■ OPQ
■ CASLPA
■ CASP
■ CEC
■ CPA
■ Other ______________________________________________
■ INS
Please continue on other side...
Evidence of Appropriate Training in the Use of Tests
Have you successfully completed a graduate course(s) in Assessment? Yes ■ No ■
Course Names(s) _________________________________________________________________________________________________________
Have you successfully completed a practicum or internship in Testing? Yes ■ No ■
Course Names(s) _________________________________________________________________________________________________________
Test Usage
Have you completed other continuing education workshop/training? Yes ■
No ■
Please specify:___________________________________________________________________________________________
Continuing Education ■
Supervised Training ■
Workshop ■
Other:_____________________________________
Evidence of Acceptance of Responsibility for the Sound Use of Tests (see section entitled “Who May Purchase Tests”
on page 154)
I wish to purchase tests at the following Qualification Levels. A ■ B ■ C ■
I wish to purchase the test(s) listed on the attached order form under the following test purchaser category. Category 1 ■ Category 2 ■
Category 3 ■
I plan to use the test for purposes other than the ones outlined under these categories. I have included a letter that fully describes these other purposes.
Yes ■ No ■
■ Please check this box if you do NOT want to receive product mailings that are not in reference to product
updates or related information.
Terms of Agreement: The Psychological Corporation reserves the right to require additional evidence of each Purchaser’s qualifications.The
Psychological Corporation also has the sole right to determine whether a purchaser is qualified under each category. In addition,The Psychological
Corporation retains the right to withhold or withdraw approval for test purchases where there is evidence of violation of commonly accepted testing
practices or conditions of sale.
No tests are to be sold for self-guidance, nor to any individual or organization engaged in testing and counselling by mail.Test users must agree to
guard against the improper use of tests in order to retain the right to purchase tests.To protect their security and value, tests and scoring keys must be
kept in locked files or storage cabinets accessible only to authorized personnel.
My signature indicates that the information on this form is correct and that I agree to abide by the principles set forth under the category indicated
above in accordance with the accepted standards for the ethical and professional use of tests. I also agree to abide by the regulations that apply to the
copyrighted parts of the test(s) I wish to purchase. Copyrighted parts of tests include test items, scoring algorithms, norms, test booklets, test protocols,
etc.This material may not be reproduced on paper or electronic format without written permission from the publisher.Violation of copyright is a federal offence according to the Canadian Copyright Act, R.S.C. 1985, c.C–42.
Signature _______________________________________________________________________ Date _______________________________
Note: Graduate students must also include the signature of a faculty advisor who assumes responsibility for supervising the use of test materials.
Graduate Advisor Signature ______________________________________________________ Date _______________________________
Copy and send this form with your order to: The Psychological Corporation Qualification Section, Customer Service, 55 Horner Avenue,
Toronto, Ontario M8Z 4X6 Fax (416) 255-4046 or 1-800-665-7307