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New Member Application

Complete this application to begin your 2017 membership!

All memberships run on a calendar year, so your membership will be valid until Dec. 31, 2017.

 

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Please note that this form is for U.S. and International (non-Canadian) members, who are also not a part of the Miracle-Ear Membership Program.

  • Miracle-Ear Professionals, please go here to join.


* Indicates a required field

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Choose a Member Type

Professional (U.S.): Individuals engaged in the practice of testing human hearing and selecting fitting, counseling patients and dispensing hearing instruments.
International: Those professionals employed outside the United States or Canada.
Associate/Affiliate: Office staff, receptionists or any other support staff, educators, physicians, counselors or those employed by a hearing industry manufacturer or supplier.
Student: Individuals pursuing an academic or vocationally-based program of study in the practice of hearing instrument sciences or other related professions.

 

Membership Type *
$325 - Professional (U.S.)
$135 - Professional (International)
$55 - U.S. Associate/Affiliate
$100 Canadian Associate/Affiliate
$40 - Student


Promo Code

If you have a promo code, enter it below. Staff will check validity of promo code upon receiving your application:


Payment Method *
Visa
MasterCard
American Express
Discover

Name on Card

Card Number

Expiration Date

Security Code


Contact Info

Name (First, Middle, Last) *

Date of Birth (mm/dd/yy)

Gender
Male
Female

Last Four Digits of SS/SI Number


Home Address

Address

City

State/Province

Zip/Postal Code

Country

Phone

 

Business Address

Company Name

I am...
an Employee
the Business Owner

Number of offices:

Number of dispensers:

Do you train apprentices?
Yes
No

Address line 1

Address line 2

City

State/Province

Zip/Postal Code

Country

Phone

Fax

Email *

Website


Are you a military veteran?
Yes
No


If you are a veteran, in which branch did you serve?
Air Force
Army
Coast Guard
Marines
Merchant Marines
National Guard
Navy
Reserves

 

What is Your Preferred Mailing Address? *
Business
Home


Professional Info

Which title best describes you? *
Audiology Assistant
Audiologist
Consultant
ENT
Hearing Aid Specialist
Manufacturer
Office Staff
Professor
Educator
Other



Is this a second career for you or have you switched careers or retired from a previous profession?
Yes
No


If so, what was your previous profession?


I am licensed/qualified to dispense hearing instruments in the following states/provinces/countries:


My license/registration number is:


I began dispensing hearing instruments in (year):


Education

Education Level *
Associate Applied Sciences
Associate of Arts Degree
Associate Science Degree
Bachelor Degree
High School
Licensed Practical Nurse
Master of Arts Degree
Master of Science Degree
MBA
Medical Doctor
Other
Ph.D
Some College
Trade School

Name of Institution

If currently a student, program and anticipated licensing date

 

Advocacy

The IHS Advocacy Alliance funds legislative and regulatory efforts on behalf of the membership. To contribute, check the box that indicates your level of support.


$25
$50
$100
$250

Other Amount - please specify below

 

Terms and Conditions

I agree to abide by the Bylaws and Code of Ethics of the International Hearing Society.

Do you agree with these terms?
Yes
No