Pdf Qualification Form

Qualifications To Purchase

Please provide us with the following information to establish your qualifications for this and future purchases.

Completion of this form is not required of licensees ordering for a regionally accredited college, or university or a
federal or state agency if, and only if, an official purchase order is used and payment is made by institutional voucher
or check.

Name: ____________________________________________________________________________

Title:_______________________________________ Organization:___________________________

Organization Name:_________________________________________________________________

Address:__________________________________________________________________________

City:__________________________________________ State:_______________ ZIP:____________

Phone:____________________________ FAX:___________________ E-Mail:__________________

Primary Type of Practice: Private Practice/Personal Organization/Institution

Highest Professional Degree Attained: Doctorate Master's Bachelor's

Institution:__________________________________ Field:___________________ Year:_________

Course Work Completed in Tests and Measurements:

Course:____________________________________ Date:__________ Institution:_______________

Categorize Type of Work:

Business K-12 Government University Other:______________________

Indicate Your Primary Purpose For Using the Test(s):

Career Counseling Organizational Development Personnel Development

Personal Counseling Therapy/Private Consulting Other:______________________

I certify that all the information contained in this form is accurate. I certify that any test products that
I purchase from Moving boundaries will be used by me and/or members of my institution or
organization in accordance with the Standards of Educational and Psychological Testing. I further
agree to abide by the terms set forth in the Moving Boundaries catalog.

I agree that Moving Boundaries' test instruments are licensed and not sold to me, and I agree not to resell, sublicense, export, redistribute or otherwise transfer for use by any third person or entity any copy of any such instruments.

Signature:__________________________________________________ Date:__________________

(If you are a student you must have a qualified supervisor's signature in addition to your own.)

Signature:__________________________________________________ Date:__________________

(I agree to supervise this student's use of the ordered items and endorse this statement.)

Print and Fax this signed form to Moving Boundaries at: (503) 661-5304

Or mail to:

Moving Boundaries, inc
1375 S.W. Blaine Court
Gresham, OR 97080

If you need further information on how to get qualified, please contact Moving Boundaries at (503) 661-4126.