{"id":3117,"date":"2024-01-02T16:03:31","date_gmt":"2024-01-02T15:03:31","guid":{"rendered":"https:\/\/www.smartbrain.es\/smartbrainen\/?page_id=3117"},"modified":"2026-03-18T18:12:25","modified_gmt":"2026-03-18T17:12:25","slug":"formulario-de-compra-smartbrain-web","status":"publish","type":"page","link":"https:\/\/www.smartbrain.es\/smartbrainen\/formulario-de-compra-smartbrain-web\/","title":{"rendered":"Subscription form"},"content":{"rendered":"\n<p class=\"has-medium-font-size\"><\/p>\n\n\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Purchase Smartbrain WEB<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_9'  action='\/smartbrainen\/wp-json\/wp\/v2\/pages\/3117' data-formid='9' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_9' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_9_116\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_116'>LinkedIn<\/label><div class='gfield_description' id='gfield_description_9_116'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_116' id='input_9_116' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_9_107\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_107'>Type of use of the program<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_9_107'>Select the type of use of the Smartbrain Program you intend to do by checking one of the following boxes:<\/div><div class='ginput_container ginput_container_select'><select name='input_107' id='input_9_107' class='large gfield_select'  aria-describedby=\"gfield_description_9_107\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select an option<\/option><option value='Professional use' >Professional use<\/option><option value='Second Choice' >Individual use<\/option><\/select><\/div><\/div><fieldset id=\"field_9_108\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Rate<\/legend><div class='gfield_description' id='gfield_description_9_108'>Indicate the rate you want to subscribe to<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_108'>\n\t\t\t<div class='gchoice gchoice_9_108_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='Month to month payment - 75 US dollars \/month excluding VAT'  id='choice_9_108_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_9_108\"   \/>\n\t\t\t\t\t<label for='choice_9_108_0' id='label_9_108_0' class='gform-field-label gform-field-label--type-inline'>Month to month payment &#8211; 75 US dollars \/month excluding VAT<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_108_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='One year payment in advance - 749 US dollars VAT excl.'  id='choice_9_108_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_108_1' id='label_9_108_1' class='gform-field-label gform-field-label--type-inline'>One year payment in advance &#8211; 749 US dollars VAT excl.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_109\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Rate<\/legend><div class='gfield_description' id='gfield_description_9_109'>Indicate the rate you want to subscribe to<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_109'>\n\t\t\t<div class='gchoice gchoice_9_109_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='Month to month payment - 20 US dollars\/month excluding VAT'  id='choice_9_109_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_9_109\"   \/>\n\t\t\t\t\t<label for='choice_9_109_0' id='label_9_109_0' class='gform-field-label gform-field-label--type-inline'>Month to month payment &#8211; 20 US dollars\/month excluding VAT<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_109_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='One year payment in advance - 199 US dollars VAT excl.'  id='choice_9_109_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_109_1' id='label_9_109_1' class='gform-field-label gform-field-label--type-inline'>One year payment in advance &#8211; 199 US dollars VAT excl.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_16\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_9_18\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">1.-  DATA OF THE ENTITY OR PERSON WHO PURCHASES THE LICENSE<\/h3><\/div><div id=\"field_9_20\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_20'>Name of entity<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_9_20' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_19\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >First and last name of contact person*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_9_19'>\n                            \n                            <span id='input_9_19_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_9_19_3' class='gform-field-label gform-field-label--type-sub '>Name<\/label>\n                                                    <input type='text' name='input_19.3' id='input_9_19_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_9_19_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_9_19_6' class='gform-field-label gform-field-label--type-sub '>Last name<\/label>\n                                                            <input type='text' name='input_19.6' id='input_9_19_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_9_111\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_111'>Country<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_111' id='input_9_111' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Spain' >Spain<\/option><option value='Argentina' >Argentina<\/option><option value='Chile' >Chile<\/option><option value='Colombia' >Colombia<\/option><option value='USA' >USA<\/option><option value='Italy' >Italy<\/option><option value='Latvia' >Latvia<\/option><option value='Mexico' >Mexico<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_9_112\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_112'>Specify country<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_112' id='input_9_112' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_113\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >How did you get to know about us?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_113'>\n\t\t\t<div class='gchoice gchoice_9_113_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_113' type='radio' value='Internet'  id='choice_9_113_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_113_0' id='label_9_113_0' class='gform-field-label gform-field-label--type-inline'>Internet<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_113_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_113' type='radio' value='Centro Breyna \/ Dr. Conrado Estol'  id='choice_9_113_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_113_1' id='label_9_113_1' class='gform-field-label gform-field-label--type-inline'>Centro Breyna \/ Dr. Conrado Estol<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_113_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_113' type='radio' value='Tienda Sensorial Argentina'  id='choice_9_113_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_113_2' id='label_9_113_2' class='gform-field-label gform-field-label--type-inline'>Tienda Sensorial Argentina<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_113_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_113' type='radio' value='Recommendation from a specialist'  id='choice_9_113_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_113_3' id='label_9_113_3' class='gform-field-label gform-field-label--type-inline'>Recommendation from a specialist<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_113_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_113' type='radio' value='Recommendation from a relative or friend'  id='choice_9_113_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_113_4' id='label_9_113_4' class='gform-field-label gform-field-label--type-inline'>Recommendation from a relative or friend<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_113_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_113' type='radio' value='Other'  id='choice_9_113_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_113_5' id='label_9_113_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_115\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >How did you get to know about us.?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_115'>\n\t\t\t<div class='gchoice gchoice_9_115_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='Internet search'  id='choice_9_115_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_115_0' id='label_9_115_0' class='gform-field-label gform-field-label--type-inline'>Internet search<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_115_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='Recommendation from a family association'  id='choice_9_115_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_115_1' id='label_9_115_1' class='gform-field-label gform-field-label--type-inline'>Recommendation from a family association<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_115_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='Recommendation from a specialist'  id='choice_9_115_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_115_2' id='label_9_115_2' class='gform-field-label gform-field-label--type-inline'>Recommendation from a specialist<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_115_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='Recommendation from a relative or friend'  id='choice_9_115_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_115_3' id='label_9_115_3' class='gform-field-label gform-field-label--type-inline'>Recommendation from a relative or friend<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_115_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='Other'  id='choice_9_115_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_115_4' id='label_9_115_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_114\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_114'>Specify other<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_114' id='input_9_114' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_27\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_9_27' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_9_27_1_container' >\n                                        <label for='input_9_27_1' id='input_9_27_1_label' class='gform-field-label gform-field-label--type-sub '>Full postal address<\/label>\n                                        <input type='text' name='input_27.1' id='input_9_27_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_9_27_3_container' >\n                                    <label for='input_9_27_3' id='input_9_27_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_27.3' id='input_9_27_3' value=''    aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_9_27_4_container' >\n                                        <label for='input_9_27_4' id='input_9_27_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                        <input type='text' name='input_27.4' id='input_9_27_4' value=''      aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_9_27_5_container' >\n                                    <label for='input_9_27_5' id='input_9_27_5_label' class='gform-field-label gform-field-label--type-sub '>Zip code<\/label>\n                                    <input type='text' name='input_27.5' id='input_9_27_5' value=''    aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_27.6' id='input_9_27_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_9_28\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_left_half gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_28'>Phone number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_28' id='input_9_28' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_29\" class=\"gfield gfield--type-email gfield--input-type-email gf_right_half gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_29'>Email address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_29' id='input_9_29' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_9_31\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_9_32\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">2.- PAYMENT<\/h3><\/div><div id=\"field_9_33\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_33'>Payment method<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_33' id='input_9_33' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select payment method<\/option><option value='Funds transfer' >Funds transfer<\/option><option value='Credit card' >Credit card<\/option><\/select><\/div><\/div><div id=\"field_9_82\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><H5><b>Funds transfer<\/b><\/H5>\n<h5>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 <br>Account number: <b>IBAN: ES55 0081 0231 9200 0168 7770 \u2013 SWIFT\/BIC: BSABESBBXXX <\/b><\/h5><\/div><div id=\"field_9_41\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_41'>Credit card<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_9_41'><h5>Indicate the details of the card with which you want to make the payment. Payment by card carries a management fee of 2% <\/b> of the purchase amount. <\/h5><\/div><div class='ginput_container ginput_container_select'><select name='input_41' id='input_9_41' class='medium gfield_select'  aria-describedby=\"gfield_description_9_41\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Visa' >Visa<\/option><option value='Mastercard' >Mastercard<\/option><option value='Eurocard' >Eurocard<\/option><option value='Tarjeta 6000' >Tarjeta 6000<\/option><option value='JCB' >JCB<\/option><option value='Maestro' >Maestro<\/option><option value='EDC' >EDC<\/option><option value='Clau' >Clau<\/option><\/select><\/div><\/div><div id=\"field_9_45\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_45'>Card number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_9_45' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_43\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_43'>Month of expiry<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_43' id='input_9_43' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='January' >January<\/option><option value='February' >February<\/option><option value='March' >March<\/option><option value='April' >April<\/option><option value='May' >May<\/option><option value='June' >June<\/option><option value='July' >July<\/option><option value='August' >August<\/option><option value='September' >September<\/option><option value='October' >October<\/option><option value='November' >November<\/option><option value='December' >December<\/option><\/select><\/div><\/div><div id=\"field_9_44\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_44'>Year of expiry<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_44' id='input_9_44' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='2023' >2023<\/option><option value='2024' >2024<\/option><option value='2025' >2025<\/option><option value='2026' >2026<\/option><option value='2027' >2027<\/option><option value='2028' >2028<\/option><option value='2029' >2029<\/option><option value='2030' >2030<\/option><option value='2031' >2031<\/option><option value='2032' >2032<\/option><\/select><\/div><\/div><div id=\"field_9_42\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_42'>Name of card holder<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_9_42' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_89\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_9_48\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">3.- INVOICING:<\/h3><\/div><div id=\"field_9_49\" class=\"gfield gfield--type-select gfield--input-type-select field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_49'>Invoice<\/label><div class='ginput_container ginput_container_select'><select name='input_49' id='input_9_49' class='small gfield_select'     aria-invalid=\"false\" ><option value='No' selected='selected'>No<\/option><option value='' >Yes<\/option><\/select><\/div><\/div><div id=\"field_9_50\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_50'>Name of entity or person to be invoiced<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_9_50' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_51'>VAT number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_9_51' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_52\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_52'>Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_9_52' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_53\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_53'>Zip code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_9_53' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_55\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_55'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_9_55' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_56\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_56'>Country<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_9_56' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_103\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_9_106\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Legal notice<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_9_106'><h6>As soon as we receive this purchasing form of a license for using the Smartbrain Program correctly filled out, indicating the type of use foreseen and the desired fee, and we have confirmed the first payment, we will send you by e-mail the confirmation of registration in the program and the access keys to the program as administrator of the license. With these keys, which will already be active, you will be able to access the program immediately and use it to register your tutors, without limitation of number, who in turn will be able to register the users\/patients, also without limitation of number. 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, domiciled in Calle Pico Balaitus 1 1C &#8211; 28035 Madrid, telephone: (+34) 609 792 358 and email: info@smartbrain.es; and that we will treat the information you provide in order to provide the requested service and perform the billing of the same. The data provided 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 obtain 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 authorization to provide you with information about our products and services related to those requested, and to retain you as a customer, by checking one of the following boxes:\n <\/h6><\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_106'><div class='gchoice gchoice_9_106_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.1' type='checkbox'  value='Yes'  id='choice_9_106_1'   aria-describedby=\"gfield_description_9_106\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_106_1' id='label_9_106_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_106_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.2' type='checkbox'  value='No'  id='choice_9_106_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_106_2' id='label_9_106_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_9' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Send'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_9' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_9' id='gform_theme_9' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_9' id='gform_style_settings_9' value='{&quot;inputPrimaryColor&quot;:&quot;#204ce5&quot;}' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_9' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='9' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_9' 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