-Get listed gold

GOLDLISTING REGISTRATION FORM

LOGIN information:
(with your user ID & password, you will be able to access and modify your listing)

User ID	You must enter a User Id
Password:	from 5 to 10 letters or numbers. You must enter a password
Confirm password:	Write the same password to verify that there is no mistake. You must confirm the password
Your email address:	This email address will be used to communicate with you (information) and will not be seen on the Health Yellow Book Directory to protect your privacy against SPAM. You must enter a valid email

Personal Information that will appear on the Health Yellow Book site :

Sex :	Male Female You must choose male or female
Last name	Enter your last name
First name	Enter your first name
Business name if any:
Address of your practice:	Enter the address of your practice
Zip code:	Enter your Zip code
City:	Enter a city
Addition to address: (when applicable)	Cedex, province, etc...
Country	Choose a country
Telephone number:	Enter a telephone number country code-area code-number
Second telephone number:
Fax
Web Site

Other Information :

Status	Choose a status
License(s) number(s):	Enter a license number

In which modalities would you like to be listed?
Note : Modality 1 should be your primary practice. (we have listed the main therapies to be user friendly for the site visitors).

Modality 1:	Choose at least one modality
Modality 2:
Modality 3:
Modality 4:
Modality 5:
Modality 6:
Modality 7:
Modality 8:
Modality 9:
Modality 10:
If you do not find your modality, please choose one in the list that is closer to your practice. Then inform us of the modality that you would like/need to be listed by sending us an email (click here). If your request is acceptwd, you will receive an email, and be able to modify your listing.

Please enter below the location (s) of your practice (s)

How do you work ?

Individual Session	Children
Group	Workshop/Seminar
Couple	Other

Your presentation:
you, your method, your approach, your activity (you have up to 500 characters)

A picture/photo of your choice(optional):
Browse here to select a photo from your hard drive. If you do not have a photograph at this time, you will be able to include one later on.


Picture/photo:
Format JPG. required The photograph will be automatically reduced if oversized

IMPORTANT:
Please enter your professional title or the modality that defines your practice the most : It will appear next to your name in the directory.

Professional Title:	Example "OMD",or "LMT-CST-D", or "PhD",or "Dance Therapist" Enter a professional title

If you have a sponsor code, please enter it here to benefit from the special offer :


How did you heard about us?

I have read and accept the General conditions of sales

The information given are for Health Yellow Book™ and WHODRAM™ only. We may share these information with a third party, in accordance and respect of your deontology code. You are reminded that you have the right to access, modify, remove any of your personal information.

Terms of registration in the Health Yellow Book™ Directory as a Silver or Gold Listing : The general terms of registration are between CONCEPT AND CHALLENGE (the Company) and the client (the Registered Client) who has registered in the Directory www.healthyellowbook.com , www.healthyellowbook.org or in www.whodram.com. www.whodram.org The registration to the Directory is reserved to any professional healthcare practitioners holding an active license, or a state certification, or who holds a diploma from a recognized school in Natural Health, or is a minister, if you are working either as an employee, an independent contractor, in private practice, own or works in a health care related business or for a non profit health organization.