Heath Media Application

1
Select Which One Applies To You:* This field is required.We ask so we can cater our services to your specific business model
Ecom Brand Owner
Online Coach / Consultant
Service Based Business
Marketing Agency Owner
Media Buyer for Company or Freelance (I'm Applying for Myself)
I Work For A Company In Management or Marketing (I'm Applying On Behalf of My Company)
Other
2
What is your name?* This field is required.
First Name
Last Name
3
What is your website? (If you have no website, type your Business Name instead)* This field is required.
4
Location (Where are you based)* This field is required.
Please Select
Please Select
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua y Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermudas
Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Brazil
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Channel Islands
Chile
China
Colombia
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominican Republic
Dominique
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadalupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstán
Kenya
Kirgyzstan
Kiribati
Korea
Kuwait
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zeland
Nicaragua
Níger
Nigeria
Niue
Norfolk Island
North Korea
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine. Observer State, non-member of the United Nations
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion Islands
Rumanía
Russia
Rwanda
Saint Helena
Saint Kitts and Neviss
Saint Lucia
Saint Martin (Dutch part)
Saint Vincent and the Grenadines
Samoa
San Bartolome
San Marino
San Martin (French part)
San Pedro and Miquelon
Sao Tomé and Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovak Republic
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Surinam
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmeinetan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
Union of Comoros
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands of the United States
Wallis and Fortuna
West Sahara
Yemen
Zambia
Zimbabwe
5
What is your current monthly revenue?* This field is required.We ask to understand how your business is doing and how we can help you reach the next level.
$0 - $10,000
$10,000 - $20,000
$20,000 - $30,000
$30,000 - $50,000
$50,000 - $100,000
$100,000 - $250,000
$250,000 - $500,000
$500,000 - $1,000,000
$1,000,000 +
6
What is your email?* This field is required.Make sure you don't type your email incorrectly so we can confirm your application
example@example.com
7
What is your number?* This field is required.Make sure you don't type your number incorrectly so we can confirm your application
8
Which of the following best describes your situation and what you're looking for?* This field is required.
Done-For-You Service - We handle everything for you, so you can focus on running your business. Ideal if you want expert execution without lifting a finger.
Mentorship - You run the campaigns, we guide you step-by-step. Includes 1:1 daily support, hands-on feedback, and direct access to our proven frameworks. Ideal if you want to stay in control, but scale with expert guidance in your corner.
9
We're done here. Hit YES to submit!* This field is required.
YESNO
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