If you are submitting a purchase order, please attach it to this completed order form.

1 Customer Account Information ORDER FORM

Customer Account Owner Number_____________________________
(find number on recent invoice or packing slip) Phone: 888.783.6363

Account Owner Name ________________________________________________________

Email: [email protected]

Account Owner E-mail address _____________________________________ Bill to (if different)

Account Owner Phone ( ) ______________________________________________ Name _________________________________________________________________________

Title ___________________________________________________________________________
2 Activate and Ship to Organization __________________________________________________________________

Name _________________________________________________________________________ Street _________________________________________________________________________

Title ___________________________________________________________________________ City ______________________________ State ________ Zip ____________ +

Organization __________________________________________________________________ Phone ( ) ______________________________________________________________

Street _________________________________________________________________________ Fax ( ) _________________________________________________________________

City ______________________________ State ________ Zip ____________ + E-mail _________________________________________________________________________

Phone ( ) ______________________________________________________________ First Order? • Please establish your qualification level (see reverse side)
• Include prepayment
Fax ( ) _________________________________________________________________ Renewing? • P  lease provide your current license/panel
number(s)________________________
E-mail _________________________________________________________________________

3 RehaCom® In Clinic Licenses & Equipment

Select
Product Number ISBN Price* Quantity Sub-Total

Initial Annual Starter Licenses (these licenses include a RehaCom panel)

1 year license (includes Panel) 0150303033 $1,495.00

3 year license (includes Panel) 015030305X $3,300.00
5 year license (includes Panel) A103000130461 $5,000.00
7 yeat license (includes Panel) A103000130462 $ 6,300.00
Annual Renewal Licenses
1 year renewal license 0150303009 $1,250.00
3 year renewal license 0150303025 $3,000.00
5 year renewal license A103000130200 $4,000.00
7 year renewal license A103000130201 $5,200.00
Additional RehaCom Equipment
Panel 0150303092 $500.00
Chin rest 0150303327 $200.00
RehaCom Server Dongle (also requires multiple licenses to be ordered) A103000130197 $300.00
Hourly Home Training Packages (must be added to an existing RehaCom license)
DISCOVER pkg 400 hours A103000196659 $800.00
CLASSIC pkg 800 hours A103000196660 $1,500.00
POWER pkg 1600 hours A103000196661 $2,800.00

Prices are valid through December 31, 2021 and are subject Subtotal $
to change without notice.
4 Shipping Add your state
and local tax $
•Call for shipping information $
Total $

P H O N E 888-783-6363 | PearsonAssessments.com/RehaCom
 5 Payment 6 Authorization, Prices and Terms
n Purchase Order # ____________________________________________________________________ Prices effective from January 1, 2019 to December 31, 2021 and subject to change without notice.
Terms are balance net 30 days. Risk of loss is FOB destination with shipping charges added to invoice.
n Check enclosed payable to NCS Pearson, Inc. Check #_ Amount $__________ I authorize Pearson to ship this order and agree to Pearson’s Terms and Conditions of Sale and Use of
Pearson Products, their Qualification Policies, and their Return Policy.
n Credit card: *Please provide the best contact number to reach you
between the hours of 7:00 am and 6:00 pm Central Time:
Signature _________________________________________________________
Phone Number _______________________________________________________________________
*Pearson can only accept credit card payments through the e-commerce portal, Title ___________________________________________ Date _____________
call center, or remote call centers at selected events. Credit card information is not
accepted via paper orders to protect your personal information.

QUALIFICATION POLICIES & USER ACCEPTANCE FORM

Qualifications Policy
Please establish your qualification level for this and future purchases by completing the User Acceptance Form. You may also complete the form online at
PearsonClinical.com.
Pearson is committed to maintaining professional standards in testing and professional practice as presented in the Standards for Educational and Psychological
Testing published by the American Educational Research Association (AERA), American Psychological Association (APA), and the National Council on Measurement
in Education (NCME). A central principle of professional use is that individuals should use only those products for which they have the appropriate training and
expertise. Pearson supports this principle by stating qualifications for the use of particular tests and interventions, and selling products to individuals who provide
credentials that meet those qualifications. The policies that Pearson uses to comply with professional testing practices are described below.
The “User” is the individual who assumes responsibility for all aspects of appropriate use, including administration, scoring, interpretation, and application of results.
Some tests may be administered or scored by individuals with less training, as long as they are under the supervision of a qualified User.
Each test manual will provide additional detail on administration, scoring, and/or interpretation requirements and options for the particular test.
We accept orders from individuals when a User Acceptance Form
has been submitted and accepted. All products are classified by a User qualification code. See the specific product descriptions in the catalog or on the Web for these
qualification levels.
QUALIFICATION LEVEL A:
There are no special qualifications to purchase these products.
QUALIFICATION LEVEL B:
Products may be purchased by individuals with:
• A master’s degree in psychology, education, occupational therapy, social work, or in a field closely related to the intended use of the assessment, and formal
training in the ethical administration, scoring, and interpretation of clinical assessments.
OR
• Certification by or full active membership in a professional organization (such as ASHA, AOTA, AERA, ACA, AMA, CEC, AEA, AAA, EAA, NAEYC, NBCC) that requires
training and experience in the relevant area of assessment.
OR
• A degree or license to practice in the healthcare or allied
healthcare field.
OR
• F ormal, supervised mental health, speech/language, and/or educational training specific to assessing children, or in infant and child development, and formal
training in the ethical administration, scoring, and interpretation of clinical assessments.
QUALIFICATION LEVEL C:
Tests with a C qualification require a high level of expertise in test interpretation, and can be purchased by individuals with:
• A doctorate degree in psychology, education, or closely related field with formal training in the ethical administration, scoring, and interpretation of clinical
assessments related to the intended use of the assessment.
OR
• L icensure or certification to practice in your state in a field related to the purchase.
OR
• Certification by or full active membership in a professional organization (such as APA, NASP, NAN, INS) that requires training and experience in the relevant
area of practice.

P H O N E 888-783-6363 | PearsonAssessments.com/RehaCom
QUALIFICATION POLICIES & USER ACCEPTANCE FORM Questions?
Call 888.783.6363

User Acceptance Form

*Name___________________________________________________________________________________________
*Organization Name____________________________________________________________________________
*Telephone__________________________________ *Fax______________________________________________
*E-mail___________________________________________________________________________________________
*Address_________________________________________________________________________________________
*City __________________________ *State________ *Zip___________ *Country___________________________
1.Professional Title n Psychologist–Clinical
n Audiologist n Psychologist–Forensic
n Consultant/Specialist–Education n Psychologist–Industrial/Occupational
n Counselor–Family/Mental Health/Substance Abuse n Psychologist–Neuro
n Counselor–Vocational/Academic n Psychologist–School
n Director–Clinical Training n Psychometrist
n Early Childhood Professional n Public Safety Official
n Education Professional n School Social Worker
n Educational Diagnostician n Social Worker
n Human Resources Professional n Special Education Professional
n Nurse n Speech Language Pathologist
n Occupational Therapist n Student/Intern
n Physical Therapist n Teacher
n Physician n Testing Coordinator
n Principal n Training Development Professional
n Professor n Other: _____________________________________
n Psychiatrist
2. Primary Work Setting: Mental Health & Counseling
Education n Psychology & Counseling
n Public School n Hospital/University Hospital
n Private School n Neuropsychology
n Post-Secondary 4-year n Forensic Practice
n Post-Secondary 2-year n Psychiatric Practice
n Technical/Vocational College n Speech and Language
n Head Start n Audiology
n Daycare/Preschool n Substance Abuse
n Other: __________________________________________________ n Career Counseling
n Occupational Therapy
Government n Physical Therapy
n Corrections n Nursing Home/Assisted Living
n Public Safety/High-Risk
n Military/VA Medical Specialty
n CMHC (e.g., Pain, Bariatrics, Rehab)
n Federal/State/Local Org n __________________________________________
n Other (please specify)_________________________________
3. Highest professional degree attained:
*Degree_____________________________________ *Major Field________________________ *Year______________________ *Institution _________________________________________________________
4. Course work completed in Tests and Measurement: yes or no
If yes *Date_____________________________________*Course_____________________________________________________
*Institution____________________________________________________________________________________________________
n graduate level n undergraduate level
5. Valid license or certificate issued by a state regulatory board:
*Certificate/License Type_____________________ *Number_____________________________________________________
*Certifying or Licensing Agency______________________________________________________________________________
*State__________________________________ *Expiration Date_____________________________________________________
6. I have Full and Active Membership in the following Professional Organization(s):
n ASHA n AOTA n APA n AERA n ACA n AMA n NASP n NAN n INS n CEC n AEA n AAA n EAA n NAEYC n NBCC n OTHER
Member No. _____________________________________________________________Member Type_______________________
I agree:
• To update my information upon request.
• I am qualified to properly use any Pearson Products I order, and I have provided Pearson with only accurate and true qualification information.
• A ny Pearson Products purchased under my account will be used by me and/or under my supervision.
• A ny Pearson Products purchased under my account will be used in accordance with all applicable legal and ethical guidelines.
• I have read and hereby agree to and accept Pearson’s Terms and Conditions of Sale and Use of Pearson Products on all orders for my account and will abide by the Pearson Terms and Conditions and Qualification
Policies (as may be modified or amended at PearsonClinical.com).
• I will not resell or reproduce any Pearson Products.
• Any violation of Pearson’s Terms and Conditions of Sale and Use may result in the revocation of my right to purchase as a qualified Customer. If there are any changes that may affect my qualfication to
purchase, I will immediately notify Pearson of such changes.

*Signature___________________________________________________________________ *Date____________________________________
* Required fields

We are committed to supporting the professional standards of

our Customers, the integrity of our respected assessments and interventions, and the ethical obligations outlined by the American Psychological Association.

Copyright © 2021 Pearson Education. All rights reserved. Pearson is a trademark, in the U.S. and/or other countries, of Pearson plc. RehaCom is a registered trademark of HASOMED
GmbH. Pearson Clinical Assessment, a business unit of NCS Pearson, Inc., is the authorized distributor of RehaCom within the United States. CLINA29317-Main ML 5/21