Application for Research Discount

Fill in the form below and submit by clicking the Submit button at the end of the form, or use your browser to print this page, and send it to the Permissions Manager.

1. Investigators

Student/Principal Investigator
Name:
Telephone:
Email:
Complete Address:	University: Department: Street: City: Province/State: Country: Postal/Zip Code:

Supervisor and/or Other Investigator(s)
Name:
Telephone:
Email:
Complete Address:	University: Department: Street: City: Province/State: Country: Postal/Zip Code:

2. Qualifications of Applicant

Highest Level of Education:
Complete the Test User Qualifications Form.
The researcher must meet User Qualifications requirements.
Graduate students must have their supervisor sign the application form whereby their advisor agrees to oversee the use of the materials.

3. Abstract/Research Summary

Description of research (50 words or less) including the purpose and hypotheses:

4. Method

Description of the sample (number and demographics). Include translation language, if applicable:

Name of the test and form to be used. If only a portion of a test is to be used, provide the name of the scale(s):

Description of other predictor(s) and criterion measure(s) to be used in the study:

Brief summary of the procedures (50 words or less). If applicable, URL address for web-based studies PLUS access passwords:

5. Data Collection Period

Anticipated Start Date:
Anticipated Completion Date:

6. Study Completion Date

Anticipated Study Completion Date:

7. Conditions

Authorized Use
The research discount and use of the requested test materials is only applicable to the research study described in this application.
Translations
SIGMA retains all ownership rights to the translated test materials. You will be issued a license to use the translated version. A copy of the translated version will be submitted to SIGMA once completed. The investigators must also include the following disclaimer (in the translated language) as a footer at the bottom of each page of the assessment:
"This assessment was translated under license from SIGMA Assessment Systems, Inc. SIGMA has not reviewed this translation and is not responsible for its quality. SIGMA disclaims any liability associated with this translated work."
Prohibited Use
The research discount and use does not include the right to adapt, revise, or otherwise reproduce, publish, or distribute any copies of the test materials (neither separately nor as part of a larger publication, such as in articles, books, research bulletins, or dissertations, neither in print, nor electronically, nor by any other means), except as specifically permitted by sections entitled Authorized Use and Reproduced by Permission.
Reservation of Rights
All rights in the assessment(s) not herein granted to the investigators are expressly reserved by SIGMA Assessment Systems, Inc.
Non-Transferability
The research discount is non-transferrable. Any attempt to transfer the research discount will automatically revoke it.
Reproduced by Permission
Any copy, reproduction, or other use authorized hereby shall be accompanied by full reference to the source of the original material and the author(s). The statement shall include the phrase:
"Reproduced by Permission of SIGMA Assessment Systems, Inc., P.O. Box 610984, Port Huron, Michigan, USA 48061-0984"
All translated copies shall also bear the appropriate copyright notice that appears on the cover of the material used. This notice shall appear on the title page of each reproduction or copy of the work.

8. Supervision

	I am a principal investigator. My supervisor has endorsed my application below.
	I confirm that the individual listed below is qualified and is willing to supervise the use of the assessments purchased.

Principal Investigator's Name
Date
Supervisor's Name
Date

9. Submission

By checking the box below, I agree:

that the information provided is true and accurate.
to only use the requested assessment(s) for the research described above and understand that I must maintain the security of test materials at all times.
to send SIGMA Assessment Systems, Inc. a copy of the final research report and the collected data.

I agree