Individual Test Purchasers Qualification Form

First-time test purchasers, please complete and submit a Test User Qualification Form prior to ordering. If you place an order and we don't have your complete qualification information, we will need to contact you and your order may be delayed. If you have any questions, please call us at 1-800-627-7271 between 7 am and 6 pm Monday-Friday.

At Pearson Assessments, we maintain a high commitment to professional practices in standardized testing. To help ensure the sound use of our assessments, we require that individuals purchasing our tests for the first time fill out this form. Read the “Principles of Effective Test Use” at the bottom of this form and check the form indicating your acceptance of and compliance with these principles.

* indicates required fields

* 1. Account Setup - Choose one of the following:
Establish a new account for me Add me to an existing account
If you chose "Add me to an existing account," enter account no. (if known)
* Organization Name (For personal account, enter "self")
* 2. Contact Information

* Name
* Prefix	Dr. Mr. Mrs. Ms.
* Title
* Telephone	Fax
* Email
* County
* School District (if applicable)
* Address
* City	* State * Zip
* Country

3. Valid license or certificate issued by a state regulatory board: For example, LP, LPC, LCSW or other.
* Certificate/License Number
* License Type
* Certifying or Licensing Agency
* State * Expiration Date
4. Highest professional degree attained:
* Year * Institution
* Degree * Major Field
5. Course Work Completed in Tests & Measurements:
* You must choose Yes or No:Yes, completed coursework No, didn't complete coursework
* If yes Course Date
* If yes Institution
Graduate level Undergraduate level
6. Participation in related Pearson Assessments-approved workshop:
Workshop Name
Date Location
Leader
* 7. Qualification Level you are requesting:
description of qualification levels and requirements
8. Please list tests you use on a regular basis:

9. If you have any questions or comments, list them in the following area:

I Agree that: I am qualified to properly use any Pearson Assessments products I order, and I have provided Pearson Assessments with only accurate and true qualification information. Any Pearson Assessments test products purchased under my account will be used by me and/or under my supervision. Any Pearson Assessments test products purchased under my account will be used in accordance with all applicable legal and ethical guidelines. I have read and hereby apply Pearson Assessments terms and conditions to all orders for my account and will abide by the Pearson Assessments terms and conditions and Qualification Criteria web pages.

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Customer Service: 800-627-7271 (7 AM-6 PM CST) | Inquiries: pearsonassessments@pearson.com

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