Client Information
Name: Address Line 1:  
Title: Address Line 2:    
Telephone: City:    
E-Mail: Prov / State:  
Fax:

Postal / Zip code:  
Organization Name:      
           
What is your primary work setting?
What are your Testing Applications? Check all that apply
  

Group/Sole Practice
Corrections
Hospital

 Community Clinic
College/University
Other		 Adult Mental Health
Client Counseling
Sex Offender Program
Civil Commitment
Neuropsychology		 Adolescent Mental Health
Corrections
Pretrial/Pre-sentence
Research
Other		  
     
Valid registration, license or certificate number issued by a provincial or state regulatory board:
Highest professional degree attained:
 
Registration: Degree:  
Registration Agency:   Major Field:    
Number:   Year Completed:    
Prov / State Institution:  
Expiration Date:      
           
Graduate course work completed in Tests and Measurements:
 
Number 1          
Date:   Course:    
Institution:        
 
Number 2          
Date:   Course:    
Institution:        
 
Number 3          
Date:   Course:    
Institution:        
 
Number 4          
Date:   Course:    
Institution:        
 
Number of ADDITIONAL Licenses I would like to purchase is:  
Note: (one license is included with purchase, need an additional license for each additional psychologist)   We use a (Mac or PC)?  
I agree that:
  • I am qualified to properly use the Affinity 2.5 program and I have provided Pacific Psychological Assessment Corporation with only accurate and true qualification information.
  • The Affinity 2.5 software program purchased by me will be used by me and/or by other licensed users under my supervision.
  • The Affinity 2.5 software program purchased by me will be used in accordance with all applicable legal and ethical guidelines.
  • After submitting this request, I will read the Pacific Psychological Assessment Corporation Terms and Conditions (these will appear automatically after you select Submit Request). To complete my order, I will read, print, sign and fax this document (fax number is on the document).
 
Date:    
Contact Info: Dr. Carmen Gress, Ph.D.
Tel: 250.812.0992
Fax: 250.388.6711
E-Mail: enquire@pacific-psych.com