Becoming Technology Licensee

Organization Information

Company / Legal Entity Name

Legal Form

Country of Origin (If Indonesia, pls visit www.vanaya.co.id)

Time Zone

Head Office Address

Head Office City

Company Website

Company LinkedIn Page

Year established

Approximate number of employees

Preferred License Level

Please select one of the following license levels.

LICENSE LEVEL

INDIVIDUAL CONSULTANT

For individual consultants or small boutique firms starting to deliver Neurometric® projects at a controlled scale.
(Min. 5 reports/month)

STARTER PARTNER

For consulting or HR firms with small operational teams, beginning to serve multiple corporate clients and expanding their analytics capabilities.
(Min. 15 reports/month)

PROFESSIONAL PARTNER

For established consulting or corporate partners managing large-scale or multi-country deliveries, requiring advanced analytics and system integration support.
(Min. 30 reports/month)

Operational Readiness

EEG Device Readiness:

already owned (Emotiv Epoc X)

Not yet, will purchase from Emotiv

Primary Contact & Create Neurotech Account

Full Name

Position / Role

Work Email

Password

Phone / WhatsApp Number

Declaration

By submitting this form, I confirm that:

All information provided is accurate and can be verified.

I agree to be contacted by Vanaya NeuroTech for the next step of the licensing process.

I understand that EEG device purchase is to be made directly from Emotiv and is not included in the onboarding scope.

I understand that the Brain-Focused Coaching (BFC) Toolkit is not yet included in the current Technology Licensee package and will be offered later as an optional add-on.

Submission Date

Full Name / Signature

Becoming Technology Licensee

Expression of Interest Form

Organization Information

Preferred License Level

Operational Readiness

Primary Contact & Create Neurotech Account

Declaration

Our Location

Contact