The majority of tests offered by Derogatis Psychological Test Site are selectively available to qualified professionals in accordance with the principles represented in the Ethical Standards for Psychologists published by the American Psychological Association. Eligibility to purchase these instruments is established on the basis of professional training and experience. This form should be completed and submitted.
 
Name:      Degree:     
 
License Profession:      License Number:     
 
Address:       
 
Organization:      Job Title:     
 
Please describe the activities in which these instruments will be used:
 
Within your organization, who is responsible for supervising the use of these materials?
 
Name:      Title:     
 
Academic Training Degree Year Institution Major Field
 
 
 
I hearby certify that I and/or individuals under my supervision possess a knowledge of the basic principles of psychological measurements and of the limitations on valid interpretations as represented in the APA standards for education and psychological tests. I further certify that I am qualified to utilize the instruments purchased in a manner consistent with APA recommended standards.
 
Email Address:      Date:     
 
  If a greaduate student check here.
  Professor/Supervisor: I agree to supervise this student in the use of the test materials ordered.
 
Professor's Name:      Date:     
 
Professor's Email:     
 
Department:      Institution:     
 
  
 
 
 
 
1228 Wine Spring Lane, Towson, MD 21204, USA Phone: 1-800-245-0277 Fax: 1-410-321-6341
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