Purchaser’s Qualification Statement

For additional blank forms, please make photocopies of this form.

Name of Organization:

Type of Organization: (check all applicable boxes) ❏ Public School or School District ❏ Private School ❏ Charter School
❏ Home School / Individual Home ❏ Home School Association or Organization
❏ Commercial Business ❏ Testing or Tutoring Center ❏ Other

Please give full legal identity and describe organization:

Print Contact Name: Tel: ( )

Contact’s Title: Contact’s E-mail:

Customer Resources

Organization Address:

City/State/Zip:

Website: www.

Professional responsibilities involving use of educational/psychological tests:

List accreditations:

Membership in Professional Organizations ❏ ACA ❏ AERA ❏ APA ❏ ASLHA ❏ NASP ❏ NCME ❏ Other

The above-named customer (“Customer”) represents and warrants that:
1. Customer has a general knowledge of measurement principles and of the
limitation of test interpretations, and Customer is qualified to use and interpret
the results of the tests being purchased as recommended in the Testing
Standards.
2. Customer will adhere to the guidelines, requirements and principles
stated in the CTB/McGraw-Hill LLC catalog, the Testing Standards, and all
documentation included with or related to the Test Materials.
3. In particular, Customer agrees to comply with all security and confidentiality
requirements for Test Materials, including test results.
4. Customer will administer Tests only as directed in CTB/McGraw-Hill LLC’s
Examiner’s Manual.
5. Customer shall not reproduce or store in an electronic or other medium any
Test Materials without the prior written permission of CTB. Customer shall not
decompile, reverse engineer or disassemble any CTB Software.
6. Customer will notify CTB of any suspected breach of these conditions of which
Customer becomes aware.
CTB/McGraw-Hill respects your privacy. We use your contact information to
fulfill your requests and service your account. Your information is located in a
secure database in the U.S. and access is limited to authorized persons. From
time to time, we may share your information with other businesses within
The McGraw-Hill Companies, Inc. You can go to http://preferences.mheducation.
com/form.php or contact Privacy Officer, 20 Ryan Ranch Road, Monterey, CA
93940 or call 1.800.538.9547 to Opt Out, review your data, or ask questions.
View The McGraw-Hill Companies, Inc. Customer Privacy Policy at
http://www.mcgraw-hill.com/privacy.html.
The undersigned certifies that he/she is authorized to complete and sign this
PQS, and that the statements made in this PQS are accurate. The undersigned
agrees to notify CTB of any changes to the information contained in this PQS and
understands that submitting a PQS does not constitute an obligation on CTB’s part
to sell to any Customer.
CTB/McGraw-Hill
Customer Services Dept.
P.O. Box 881002
Indianapolis, IN 46208-1002

Signature Date

160