PURCHASE OF LICENSE FOR USING SMARTBRAIN WEB 1.- DATA OF THE ENTITY OR PERSON WHO PURCHASES THE LICENSEName of entity First and last name of contact person** Name Last name Country*Select countryEspaña peninsular y BalearesCanarias, Ceuta, Melilla o resto del mundoSpecify destination* Address* Full postal address City State Zip code Phone number*Email address* 2.- PAYMENTPayment method*Select payment methodFunds transferCredit cardFunds transfer I ill do the payment of the amount due via funds transfer, to the bank account of Smartbrain and Wellbeing, s.l. at Banc Sabadell Account number: IBAN: ES55 0081 0231 9200 0168 7770 – SWIFT/BIC: BSABESBBXXX Credit card*Indicate the details of the card with which you want to make the payment. Payment by card carries a management fee of 2% of the purchase amount. VisaMastercardEurocardTarjeta 6000JCBMaestroEDCClauCard number* Month of expiry*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear of expiry*2023202420252026202720282029203020312032Name of card holder* 3.- INVOICING:InvoiceNoYesName of entity or person to be invoiced* VAT number* Address* Zip code* City* Country* Legal notice*Legal notice: As soon as we receive this purchasing form correctly filled out, we will send you by e-mail the confirmation of your registration in the program and your access keys to use it as the administrator of the license. With these keys you will be able to access the program immediately and register your tutors, without limitation of number, who in turn will be able to register the users/patients. In compliance with the provisions of the legal regulations concerning the protection of personal data, we inform you that the personal data you provide when filling out this form will be collected in files owned by Smartbrain and Wellbeing s.l., with NIF: B87620928; address: Calle Pico Balaitus 1 1C - 28035 Madrid; telephone: (+34) 609 792 358; e-mail: email@example.com; and that we will treat the information you give us in order to provide the requested service and do the invoicing. All data will be kept as long as the business relationship is maintained or for the years necessary to comply with legal obligations. The data will not be transferred to third parties except in cases where there is a legal obligation. You have the right to get confirmation as to whether Smartbrain and Wellbeing is processing your personal data, and therefore you have the right to access your personal data, rectify inaccurate data or request its deletion when the data is no longer necessary. We also request your permission to provide you with information about our products and services and to retain you as a customer, by checking one of the following boxes: Yes No EmailEste campo es un campo de validación y debe quedar sin cambios.