Apply to be a service provider

Service Provider Application

The Listening Academy, Inc. ("TLA") provides 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

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)

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 provided by TLA, in any format or media, are protected by copyright and, as such, I will protect all TLA materials in accordance with the Terms of Use Agreement from unauthorized access, use, and exposure to any person or organization not authorized to access or use TLA systems or materials. Furthermore, any deemed failure to protect TLA materials shall result in my immediate termination as a QSP, immediate termination of all access privileges to security-protected TLA systems and materials, and immediate termination of all access privileges to security-protected TLA systems and materials and the right to use such systems and materials by my organization and all my clients and without limiting any remedies available to TLA.

In addition to being protected by copyright, all TLA systems and 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 service provider and the subsequent use of all TLA systems and materials. 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 materials under the same terms and conditions of this application and the Terms of Use Agreement.

I acknowledge that I am obliged to comply with the Personal Information Protection and Electronic Documents Act, S.C. 2000, c.5 ("PIPEDA"). 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 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 PIPEDA. Without limiting the generality of the foregoing: a) Pursuant to my own obligations under PIPEDA, 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.

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

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