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Signature Date For Internal Use Only Item and Packaging Code Number Quantity WJ IV Achievement Form A Kit Y21-1588341 WJ IV Cognitive Battery Kit WJ IV Oral Language Kit 02/14 hmhco. For more information about the Woodcock-Johnson IV please visit www. wj-iv.com. Terms of Agreement This document sets forth the terms of your institution s participation in the University Outreach Program offered by Houghton Mifflin Harcourt. Page 1 of 1 2014 Woodcock-Johnson IV University Outreach Participant Application Please fax all documents to 512-233-2489 Information Applicant Name University Name Position within the University Department Head Shipping Address City State ZIP Code Email Address Phone Number Course Title and Number Semester Fall Winter Spring Summer Number of Graduate Students in Course Standard Graduate Program Size Primary Testing Instrument Used in Course WJ IV Tests Requested/Quantity To participate in the University Outreach Program applicants must submit a Course Syllabus with the application. Applications will not be processed without an accompanying syllabus. You must complete and sign the Participant Application which will allow Houghton Mifflin Harcourt to determine the number of materials needed to supply your institution* Your signature indicates your institution s acceptance of the terms set forth in this document. The Woodcock-Johnson IV instruments may be used only for the purpose of training graduate psychology students in the use administration scoring and interpretation of these instruments and in related research. They are not to be sold distributed reproduced by photocopying or any other means or transmitted and may not be used for commercial purposes. As secure test instruments they must be kept in a secure locked location when not in use and must not be subject to access by individuals other than qualified instructors and students. The accompanying web based scoring and reporting tool is subject to the terms of the accompanying license agreement. You must complete and sign the Participant Application which will allow Houghton Mifflin Harcourt to determine the number of materials needed to supply your institution* Your signature indicates your institution s acceptance of the terms set forth in this document. The Woodcock-Johnson IV instruments may be used only for the purpose of training graduate psychology students in the use administration scoring and interpretation of these instruments and in related research. The Woodcock-Johnson IV instruments may be used only for the purpose of training graduate psychology students in the use administration scoring and interpretation of these instruments and in related research. They are not to be sold distributed reproduced by photocopying or any other means or transmitted and may not be used for commercial purposes. They are not to be sold distributed reproduced by photocopying or any other means or transmitted and may not be used for commercial purposes. As secure test instruments they must be kept in a secure locked location when not in use and must not be subject to access by individuals other than qualified instructors and students.

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