First Name*
	Last Name*
	Title
	Organization
	Street Address*
	Apt. or Suite
	City*
	State/Province*
	Zip/Postal Code*
	Country
	Work Phone*
	Home Phone
	FAX
	E-mail*
	Purchasing Plans*	1 week 1 Month 6 Months 1 Year

   I am a (select any that apply to you)*:

Psychologist                                 School Psychologist

Psychiatrist                                   Pediatrician	

Speech Language Pathologist         Social Worker

College Professor                           Researcher

Other (Please Specify)  

   I work in the following setting(s)*:

Private Practice                              Hospital/Rehab

Clinic                                             Community Mental Health

Private School                                Public School             

College or University                       Non-Profit Agency

Other setting, not mentioned above:  

Education*:

Highest Professional Degree Attained
Major Field      Year  
Institution  

Valid License/Certificate Issued By State Regulatory Board:

Certificate/License
                   State
                Number    
     Expiration Date

Membership in Professional Organizations:

APA (American Psychological Association)             NASP

APA (American Psychiatric Association)                 AMA

ASHA                                                                   AOTA
           

 Other:  

Professional Experience:

Organization: 
Position:        
Test(s) Used: 

Organization: 
Position:        
Test(s) Used: 

Other Applicable Courses/Workshops Completed:

     Title:

 Institution:      

        Date: 

         Title: 
 Institution:       
        Date: 

By submitting this form, you certify that all information provided is true and correct.  U.S. Federal law restricts the sale and usage of this system to, or on the order of, a licensed healthcare provider.  Falsification of any certification regarding the administration, use, or interpretation of BrainTrain's clinical tests or software for professionals may violate state and/or federal laws. It is the responsibility of the individual requesting the software to ascertain his/her qualifications for the usage of the software in the treatment of any medical disorders. If any violations are brought to the attention of BrainTrain by licensing agencies or psychological test regulatory organizations, BrainTrain will cooperate fully in order to resolve any issues.

                                              Check here if understood and agreed
 

How I heard about SmartMind 2?