B2B Registration - neurotech.vanaya.co

REGISTER AS

This form is intended for Starter & Professional Partner Licensees (B2B only).

Your application will be reviewed within 1x24 hours. Approval and onboarding instructions will follow by email.

Step 1 of 4

Company Name*

Company Website

Country of Incorporation*

Full Company Address*

Year Established*

Legal Entity Type*

Company Registration Number / Tax ID*

Upload Articles of Incorporation / Company Act*

Is your company part of a holding group?
Yes No

Primary Contact Person Name*

Job Title / Position*

Email Address*

Phone Number / WhatsApp*

Number of Full-Time Staff*

Operational Language(s) (e.g., English, Bahasa Indonesia, Mandarin)*

License Type Applied For*

Purpose of License Use (e.g., coaching, diagnostics, leadership development)*

Target Market Segment (e.g., corporates, education, government)*

Planned Use Cases / Applications (e.g., coaching programs, training workshops, assessments)*

Estimated Annual Client Reach*

Sales Target for Neurometric License (Year 1) (e.g., number of reports or clients planned)*

Certifications / Professional Affiliations (e.g., ICF, EMCC, IoC, ISO, etc.)

Experience with Assessments or Licensing Technologies

Do you have an internal tech / data analytics team?
Yes No

Do you own any EEG equipment?
Yes No

Additional Notes or Special Request

I hereby declare that the information provided is true and accurate.

I agree to follow Vanaya’s onboarding and training protocol.

I agree to co-brand and operate the license in alignment with Vanaya’s standards.

I commit to using this license professionally and ethically.

I will ensure proper data handling, client consent, and respect for data privacy regulations.

I confirm and agree to the above declaration

Form will be reviewed within 1x24 hours. Follow-up sent via email.

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