Research Application

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. Required fields are marked by an asterisk (*).

1. Researcher(s)

Principal Researcher
*Name:
*Phone Number:
*Email Address:
*Complete Address:	University: Department: Street: City: Province/State: Country: Postal/Zip Code:
*Mailing Address: (if different from above)	Street: City: Province/State: Country: Postal/Zip Code:

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

2. Qualifications of Principal Researcher

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 supervisor 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 of participants is REQUIRED):

*Name of the specific assessment and form to be used:

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

*Brief summary of the administration format and procedure (50 words or less):

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 assessment materials is only applicable to the research study described in this application.
Prohibited Use
The research agreement 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.
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 agreement is non-transferrable. Any attempt to transfer the research agreement will automatically revoke it.

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 non-billable research study described above.
to use the requested assessment(s) and materials subject to the terms and conditions stated in the Research Agreement.
to protect the security and integrity of test materials at all times and ensure that I am using ethical administration procedures as defined in the test manual.
to send SIGMA Assessment Systems, Inc. a copy of the final research report, a summary or abstract, and the collected data. I authorize SIGMA to copy and distribute the abstract or report to interested parties, with credit given to the authors of the research.

I agree