The Brain Republic Inc.
Memory Improvement and Accelerated Learning Program (Online Course)
Email address *
Full Name of Student (Indicate the name that you want us to put in your certificate) *
Nickname *
Sex *
Date of Birth *
MM
/
DD
/
YYYY
Age on the start of the Workshop *
Contact Numbers *
(Please indicate country code)
Promo Code
Memory Program *
Grade Level and School (For Students):
Field of Work (for Working Adults):
City and Country (Current Location): *
Language/s Spoken and Understood *
Required
Have you attended any Memory Class before or have a prior knowledge about Memory Techniques? (If Yes, tell us something about it to help you better and be able to gauge your current memory ability) *
Are you referred by any person? (If Yes, indicate his/her name on the space provided)
Other information that you think is necessary for us to know:
A copy of your responses will be emailed to the address you provided.
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