CAPDOTS - a product of The Listening Academy, Inc.
Apply to be a service provider

Service Provider Application

The Listening Academy, Inc. ("TLA") provides licensed and copyrighted therapy products to qualified service providers for non-exclusive, licensed use in the delivery of therapy programs. To ensure appropriate application of these products, a Qualified Service Provider ("QSP") must have, as a minimum, a degree in either speech-language pathology or audiology.

Last Name First Name Position/Title


Organization Name
Address City
State/Prov ZIP/Postal Code Country
Telephone (Work) Fax Email
Website

Please list your active and current Professional Regulatory Body licenses or certificates:

License # Licensing Body Country State/Province Profession

Scopes of Work (check all that apply)
Where did you hear about us?

your full name
I, , the undersigned, hereby certify that the above provided information is true, complete, and accurate. I hereby acknowledge that TLA may request additional information when reviewing this application and, that the final determination of this application remains at the complete and sole discretion of TLA.

In the event that I am accepted as a Qualified Service Provider ("QSP"), I hereby acknowledge and agree that any and all materials, programs, products, information and materials provided by TLA, in any format or media, ("TLA Materials") are protected by copyright and, as such, I will use all TLA materials in accordance with the Terms of Use Agreement and will protect the TLA Materials from unauthorized access, use, and exposure to any person or organization not authorized to access or use TLA systems or materials. Furthermore, I acknowledge that any deemed failure to protect TLA Materials or any use of the TLA Materials contrary to the Terms, shall result in my immediate termination as a QSP, immediate termination of all access privileges to security-protected TLA systems and materials, and the termination of the right to use such systems and the TLA Materials by my organization and all my clients and without limiting any remedies available to TLA its subsidiaries, affiliates, and licensors.

In addition to being protected by copyright and other intellectual property rights, all TLA systems and TLA Materials are covered by a Terms of Use Agreement that I acknowledge having had sufficient time and opportunity to read and understand before signing. I agree that the Terms of Use Agreement is a fundamental term of both my application to be a QSP and the subsequent use of all TLA systems and TLA Materials. In the event of any conflict between this Application and the Terms of Use Agreement, the Terms of Use Agreement shall apply to the extent of the inconsistency. I acknowledge and agree that the organization with which I am associated, if any, and all principals, staff, contractors and sub-contractors of the associated organization or any contractors or sub-contractors of mine as the case may be shall only have access to and use of TLA systems and TLA Materials under the same terms and conditions of this application and the Terms of Use Agreement. I acknowledge that I am responsible for any use of the TLA Materials by principals, staff, contractors and sub-contractors of my associated organization. I acknowledge that should I choose to be listed as a service provider, the display of any QSP information on the TLA website remains at the sole discretion of TLA.

I acknowledge that I am obliged to comply with privacy laws applicable to me in the collection, use and disclosure of client information. I acknowledge and agree that as long as I am a QSP and during any time thereafter that I am not a QSP but have occasion to deal with client information related to or generated from the TLA site, systems or TLA Materials, I and all those associated with me shall ensure the protection of personal information that is in my possession or custody in accordance with the privacy laws applicable to me. Without limiting the generality of the foregoing: a) I shall ensure that any and all subcontractors will ensure a comparable level of protection of personal information while in the possession or custody of client personal information; b) I agree to collect and use only the personal information necessary to fulfill my obligations herein; and c) I will not, by any means or in any format, sell, distribute, disperse, or otherwise publish any such personal information collected, created or handled under the Terms of Use Agreement. I acknowledge that TLA uses a number of web security measures including, but not limited to, IP tracking to protect its property and licensed property.

In the event that I am accepted as a QSP, I acknowledge that I am responsible for all services provided to clients using the TLA Materials. I further represent and warrant that I am qualified and hold all permits and licenses required by applicable law to provide services to clients using the TLA Materials. In the event that I lose my qualifications to provide such services, I will advise TLA and cease using the TLA Materials immediately.

In the event that I am accepted as a QSP, I acknowledge that I and my organization, if any, will provide access only to clients in the "Supplied To" states or provinces listed on the TLA license purchase receipt. Where the regions listed in the TLA license purchase receipt do not include all the states or province for which that license purchase is intended, I will immediately provide to TLA a list of any further state or province for which the license purchase is intended. I acknowledge that I or my organization may be required to remit additional monies to TLA to meet my tax compliance or my organization’s tax compliance, as the case may be, as the result of my disclosure.

I acknowledge, understand, and agree that my selection as a QSP or termination, in the future as the case may be, shall be complete, final and at TLA’s sole discretion.

  Month Day Year
Date:  

In addition to my email id, above, send a copy of this application to:

submitting