WEB ABVERTISING SUBMISSION FORM

Thank you very much for agreeing to post your add at www.TorMed.com We have to go through some formalities in order to make sure that you are you and that we understand the license under which you are willing to provide the information about your medical service.

Please fill out this form, sign it, attach your business card and mail it to us at 

TorMed

25 Fisherville Rd., #1906

Toronto, ON M2R 3B7 

Please provide your name and contact information (please print):

Your name

Phone #

Fax #

Mailing 

address

E-mail address

What kind of medical service do you provide?

________________________________________________________________________________________________________________________________________________________________________________________________________________________

Working hours

Please remember that it is your responsibility to update the provided information.

We guarantee that all changes on the site will take place within 2 business days upon receiving your update request.

Your Agreement

I warrant that I have a license to provide the medical service mentioned above. 

I have read and agree to the terms of advertising at www.TorMed.com

Signed: _______________________________________________________

In (state or province/country)______________________________________

Date__________________________________________________________

Latest revision: June 1, 2003.

This Agreement will be automatically terminated by the end of the billing period unless both TorMed and you renew it.

If you have any questions regarding this form, please contact us at info@tormed(dot-com) 
Please modify the address shown above for it to work for .com 
or call 416-739-7652