BrainRx International Application

First Name* :

Last Name* :

Today's Date* :

Birth Date* :

Email* :

Home Phone:

Work Phone:

Cell Phone:

Best phone to reach you at:

Marital Status:

Spouse's Name(if applicable):

Address* :

City* :


Postal Code:

Country* :

Education (highest level completed)* :

Education (where; major)* :

Current Business* :

Position* :

Where did you first learn about BrainRx?*

What most interests you about a BrainRx License?*

City and country you would like to operate a Center?*

Please give a brief description of the area?*

In your country region:

How much does a Bic Mac cost?* :

What does a tutoring session cost?* :

What is the average take home pay in US$?*

What is the top 30% take home pay in US$?*

Are you Interested in a master license?*

Time frame to start Center* :

What is your financial net worth?*

What experience/background do you have that makes you a good fit for a BrainRx license?*


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Don't have Skype? Get it here. BrainRx uses Skype to communicate with our applicants throughout the licensing process. It makes communication easier, and it's free. Though not a requirement, we strongly recommend it for the licensing process.