BrainRx International Application

*First Name :

*Last Name :

*Email :

*Mobile number country code :

*City :

*Country :

*Marital Status :

*Spouse's Name(if applicable) :

*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$?

*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?

* Indicates a required field.