Checkout-Result

Registration Date*

Enter Today's date

First Name*

Last Name*

Date of Birth*

Attach an updated picture of yourself*

As of January 17, 2017, you must upload a recent picture of yourself in order to receive your reading and geometric symbols. (Supported image types: .jpg .gif .png)

Email*

Phone*

Street Address*

City, State, (Province or Region), Zip*

Course/Program Selection*

Make your selection(s) below.

Discount Code

If you were given a Discount Code, please enter it here. Also, put the discounted price that you were quoted.

Account Manager

If Applicable: Select the name of the Account Manager that you have been working with to get you enrolled into the Jewel University of Immortal Sciences (JUIS).

How did you hear about us?*

Select the appropriate avenue in which you heard about our program. If you choose "Other" please explain in the comments section. If you choose "Referral": Enter the full name, phone number, and email address of the person who referred you to the Brain Balancing Program in the comments section (This mainly applies to people that are new to the program).

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