The information provided in this application will assist Pearson in evaluating your request and, if your application is approved, drafting a contract for you. 

Information submitted on this application is governed by Pearson’s Privacy Statement.


Applicant Organisation Information

This will be the “LICENSEE” for the purpose of contractual documents.








Contact person during the licensing process






Page 2

Research Project Information 









Principal Investigator






Address for providing legal notices








Address for invoicing









Page 3

Person who will sign the contractual documents







Licensed use requested





Electronic format request


If you are requesting permission to adapt Pearson materials for use in an electronic format, please provide the following information.


Due to the secure nature of Pearson’s instruments, any test materials accessible electronically and/or via a web site must not be downloadable, printable or reproducible (you cannot be able to cut/copy/paste or screen print, and mouse right-click functions must be disabled).  There must be 128-bit encryption and the site must be password protected with controlled and limited access to only select few qualified individuals. 

YOU ARE SOLELY RESPONSIBLE FOR DETERMINING WHETHER YOUR PLATFORM AND DATA PROCESSING ACTIVITIES ARE IN ACCORDANCE WITH ALL APPLICABLE LAWS AND REGULATIONS, INCLUDING BUT NOT LIMITED TO THE PROTECTION OF PII AND IP.






Pearson does not license its assessments for use on screens smaller than 9.4 x 6.6 inches.














Page 4

Adaptation proposed







Test usage details, Reproductions, and Fees

List all of the Test Components for which you are requesting a license. Specify the language(s) into which you wish to translate the component (if applicable) and the number of administrations/copies/uses you will require of each component. 

Test acronym and
component
Language  Number of uses
Applications / Uses

Reproduction of Existing Components

Do you wish to adapt and/or reproduce (portions of) a manual, stimulus book, or other component? 


If so, please indicate the component, the specific page numbers, total number of pages, and number of sets you wish to make.

Test acronym and
component
Page numbers to be 
reproduced
Total number of pages Number of sets
Reproductions

We will review the form and be in contact with any questions and to process payment.