APPLICATION FORM TO PURCHASE AND USE

ASSESSMENT MATERIALS
This form must be completed by individuals who wish to purchase psychological or educational tests and related materials. It must be also
signed by the person who will assume overall professional responsibility for the interpretation and use of such tests. Please type or print
clearly.

A. General Information
Name: __________________________________________________________ Professional Title: ________________________________________________________
Name of Organization: ____________________________________________________________________________________________________________________
Type of Organization:

Private or Public School

Business

College or University

Public or Non-profit Clinic

Medical Facility

Private Practice Clinic

Social Agency
Government Agency

Other (specify) _____________________________________________________________________________________________

Address:

Home

Office

Street : ______________________________________________________________________________ City ______________________________________________________________

Phone & Fax : _____________________________________________________________ Email: _______________________________________________________________________
Institution Add: _________________________________________________________________________________________________________________________________________
Postal Code: ________________________________________________________

B. Professional Qualification
Highest Professional Degree:
Degree ________________________ Major Field ____________________________ College/University ____________________________________ Year Received ____________

List all relevant professional associations of which you are a member: _______________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________

C. Training in Assessment
Complete this section only if you do not hold a degree(s) or license(s) that require(s) specialized training in the use of tests similar to those you wish to purchase.
Indicate the areas in which you have completed assessment coursework and supervised training.
Assessment Area

Undergraduate

Graduate

Workshop for Professional

Basic Test Measurement

Statistic
Test Use in:
Clinical Diagnosis
Counselling
Human Resource/Career Planning
Intelligence Assessment
Learning Disability Assessment
Neuropsychology
Personality Assessment
Psycho educational Planning

Other Assessment Area(s) (specify) ____________________________________________________________________________________________________

Please indicate any additional coursework, supervised training, or experience you have with tests similar to those you wish to purchase:
1.

Unit 630, 6th Floor, City & Land Megaplaza ADB Avenue corner Garnet Roads, Ortigas Center, Pasig City, Phils., 1605
Telephone Numbers: +(632) 666-5113 /706-2130; Fax Number: +(632) 325-0721
Email Address: info@v-psyche.com / Website: www.v-psyche.com

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D. Type of Materials to be Purchased

What type of materials do you plan to purchase?
Educational Tests

Personality Test

Neuropsychological Tests

Screening Materials

Game/Therapy Tests

Clinical Tests

Specific products: ________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________
What is their intended use?
Clinical diagnosis
Research

Forensic
Professional Education

Educational planning and Intervention

Screening

Mental health treatment planning and Intervention

I certify that the above information is complete and accurate to the best of my knowledge. I agree to supervise the use of all test materials
purchased from V-PSYCHE INNOVATIVE SOLUTIONS and to adhere to the professional and ethical standards of Psychology. I also agree to
recognize all copyrights and will not reproduce or cause to be reproduce in any form whatsoever, including but not limited to electronic or
computer applications, for any purpose any materials protected by copyright. I have read and agree to the foregoing statements.

_____________________________
Signature

E.

___________________________
Date

Use under supervision

Complete this section only if you are a student using materials for coursework or research.
I certify that (a) I will supervise this Individuals use of any test materials purchased from V-PSYCHE INNOVATIVE SOLUTIONS in accordance
with the Ethical Principles of Psychologists and that (b) I am qualified to do so.

Supervisors Signature: _______________________________________

Position: _____________________________________________________

Date ______________________
Highest Professional Degree: ___________________________

V-Psyche ID No:

Unit 630, 6th Floor, City & Land Megaplaza ADB Avenue corner Garnet Roads, Ortigas Center, Pasig City, Phils., 1605
Telephone Numbers: +(632) 666-5113 /706-2130; Fax Number: +(632) 325-0721
Email Address: info@v-psyche.com / Website: www.v-psyche.com