BrainRx International Application

*First Name : Please enter your first name.

*Last Name : Please enter your last name.

*Email : Please enter your email address. Email format is invalid.

*Mobile number country code :
Please enter your phone number.

*City : Please enter your City.

*Country :

*Marital Status : This field is required.

*Spouse's Name(if applicable) : This field is required.

*Education (highest level completed) : This field is required.

*Education (where; major) : This field is required.

*Current Business : This field is required.

*Position : This field is required.

*Where did you first learn about BrainRx? This field is required.

*What most interests you about a BrainRx License? This field is required.

*City and country you would like to operate a Center? This field is required.

*Please give a brief description of the area? This field is required.

In your country region:

*How much does a Bic Mac cost? This field is required.

*What does a tutoring session cost? This field is required.

*What is the average take home pay in US$? This field is required.

*What is the top 30% take home pay in US$? This field is required.

*Time frame to start Center : This field is required.

*What is your financial net worth? This field is required.

*What experience/background do you have that makes you a good fit for a BrainRx license? This field is required.

* Indicates a required field.