First Name*
	Last Name*
	Title
	Organization
	Street Address*
	Apt. or Suite
	City*
	State/Province*
	Zip/Postal Code*
	Country
	Work Phone*
	Home Phone
	FAX
	E-mail*
	Purchasing Plans*	1 week 1 Month 6 Months 1 Year

I am a (select any that apply to you)*:

Psychologist                                 School Psychologist

Psychiatrist                                   Pediatrician	

Speech Language Pathologist         Social Worker

College Professor                           Researcher

Other (Please Specify)  

I work in the following setting(s)*:

Private Practice                              Hospital/Rehab

Clinic                                             Community Mental Health

Private School                                Public School             

College or University                       Non-Profit Agency

Other setting, not mentioned above:  

Education*:
Highest Professional Degree Attained
Major Field      
         Year
Institution  

Valid License/Certificate Issued By State Regulatory Board*:
Certificate/License
              State
           Number    
Expiration Date

Membership in Professional Organizations:

APA (American Psychological Association)          NASP

APA (American Psychiatric Association)             AMA

ASHA                                                          AOTA            

 Other:  

Professional Experience:

Organization: 
Position:       
Test(s) Used:

Organization: 
Position:        
Test(s) Used: 

Other Applicable Courses/Workshops Completed:

         Title: 

 Institution:       
        Date: 

         Title: 
 Institution:       
        Date: 

By submitting this form, the person referenced in the form is certifying that he/she and/or other persons who may use the IVA test materials have a general knowledge of measurement principles and of the limitations of test interpretation as called for in the APA Standards for Educational and Psychological Tests. The individual referenced also certifies that he/she is qualified to use and interpret the results of these tests as recommended in the APA Standards.
                      

Check here if understood and agreed