Licensing Reprogram Your Weight: Application Form

Name

First Name

Last Name

Title

e.g. President, CEO, Founder

Your Email Address

Where can we contact you for questions and clarification? Not for publication.

Business Name

To be published in our book

Business Email Address

To be published in our book

Business Website

http://

Business Phone

Country

(###)

###

####

Two High Definition Image Files: Your Logo AND Your Headshot click to choose files & upload

Attach one image each of Your Logo and Your Headshot Each Image Format: JPEG Each Image DPI: 600 Each Image Dimensions: 1500 pixels on the longest edge

Short Bio

250 Characters or Less

Licensing Reprogram Your Weight: Application Form

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