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					  Customer Qualification Levels                                                     PAR Customer Qualification Form

In accordance with the Standards for Educational                Customer Information
and Psychological Testing and PAR’s competency-                    Dr.   Mr.    First                          Last
based qualification guidelines, many tests and                     Ms.   Mrs.   name _________________________ name _____________________________
other materials sold by PAR are available only to
those professionals who are trained to administer,              Customer no. _________________ E-mail address _________________________________
score, and interpret psychological tests. If you                I would like to order via your Web site. Please send me a temporary password.
have not already established a Qualification Level                 Yes No (If yes, e-mail address required above.)
with PAR, please complete the form and send it
with your first order.                                          Mailing Address                                                        Phone (_______) _____________
                                                                Organization name __________________________________________________________
Qualification Level: A
                                                                Street address ______________________________________ Suite/Apt. _______________
• No special qualifications required.
                                                                City __________________________________________ State/Province _______________
Qualification Level: B                                          Zip/Postal code _____________________Country _________________________________
• A degree from an accredited 4-year college or                 Educational Background
  university in psychology or counseling related field,
  plus completion of coursework in test interpretation,         Highest degree attained ___________________ Year degree completed _______________
  psychometrics and measurement theory, educational             Major field _________________________________________________________________
  statistics, or a closely related area;                        Institution __________________________________________________________________
• OR license or certification from an agency/                   Please check the appropriate Professional Organizational Memberships
  organization that requires appropriate training and           (If you are a full member of any of the organizations listed below, you may simply provide your
  experience in the ethical and competent use of                member number, then sign and date this form. Additional information is not required. If you are
  psychological tests.                                          not a member of any of the organizations listed, please skip to Professional Credentials.)
                                                                   APA NASP National Register of Health Service Providers in Psychology
Qualification Level: C
                                                                Membership Number_______________________________________________________________
• All Level B qualifications, plus an advanced profes-
  sional degree that provides appropriate training in the       Professional Credentials
  administration and interpretation of psychological tests;     Certificate/License (type) ______________________________________________________
• OR license or certification from an agency that requires      Certifying or licensing agency __________________________________________________
  appropriate training and experience in the ethical and        Certificate/License no. ____________________________ Exp. date ___________________
  competent use of psychological tests.
                                                                Coursework/Workshops Completed in Use of Tests
Qualification Level: S                                          Please provide the following information about your training and/or coursework. For all that
                                                                apply, indicate whether undergraduate (U) or graduate (G), name of institution or organization,
• A degree, certificate, or license to practice in a physical   and date completed.
  or mental health care profession or occupation, plus
  training and experience in the ethical administration,        Title _____________________________________________________________                                   G   U
  scoring, and interpretation of clinical behavioral
  assessment instruments.                                       Institution __________________________________________________________________
                                                                Title _____________________________________________________________                                   G   U
Certain health care providers may be eligible to
purchase selected B and C level instruments                     Institution __________________________________________________________________
within their area of expertise. Specifically,
relevant supervised clinical experience using tests             I certify that all information contained in this form is accurate. I certify that I and/or other persons
                                                                who may use any test materials I order have a general knowledge of measurement principles
(i.e., internship, residency) in combination with formal        and of appropriate and ethical test use and interpretation as called for in the Standards for
coursework (i.e., tests and measurement, individual             Educational and Psychological Testing. I also certify that I/we are qualified to use and interpret
assessment, or equivalent) qualifies a health care              the results of these tests as recommended in the Standards, and I assume full responsibility for
provider to purchase certain restricted products.               proper use of all materials I order from PAR.
                                                                Signature X ____________________________________________________________________ Date ___________________



       PAR No-Risk Guarantee                                       I am a graduate student. My professor has endorsed my order (see signature below).
                                                                   I agree to supervise this student’s use of items ordered and endorse the statement above.
     “If you are not completely satisfied with your
                                                                Professor’s name _____________________________________________________________________________
   purchase, we will accept the return of any item.”
                                                                Department ____________________________________________________________________________________
                                                                Institution _______________________________________________________________________________________

          R. Bob Smith III, PhD, Chairman and CEO               Signature X ____________________________________________________________________ Date ___________________


  Completed Qualification Forms may be submitted via fax (1.800.727.9329 or 1.813.961.2196) or mail (PAR, Inc., 16204 N. Florida Ave., Lutz, FL 33549).

				
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