Membership Type *
$325 - Professional (U.S.)
$135 - Professional (International)
$55 - U.S. Affiliate/Associate
$40 - Student
If you have a promo code, enter it below. Staff will check validity of promo code upon receiving your application:
I would like to use the installment plan option available for Professional memberships only, plus a $10 admin fee per membership. I understand that $83.75 will be charged to my card now, and the remaining $251.25 will be divided amongst the remaining quarters left in the year. My card will be charged the first Friday of every remaining quarter until all payments are completed on 9/29/2017.
Payment Method *
Name on Card
Name (First, Middle, Last) *
Date of Birth (mm/dd/yy)
Last Four Digits of SS/SI Number
the Business Owner
Number of offices:
Number of dispensers:
Do you train apprentices?
If you are Retired, what date did you retire?
Address line 1
Address line 2
What Is Your Preferred Mailing Address?
Which title best describes you? *
Hearing Aid Specialist
Is this a second career for you or have you switched careers or retired from a previous profession?
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):
Credentials (i.e., CCC-A, AuD):
Education Level *
Associate Applied Sciences
Associate of Arts Degree
Associate Science Degree
Licensed Practical Nurse
Master of Arts Degree
Master of Science Degree
Name of Institution
If currently a student, program and anticipated licensing date
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.
Other Amount - please specify below
Terms and Conditions
I agree to abide by the Bylaws and Code of Ethics of the International Hearing Society and the Canadian Hearing Instrument Practitioners Society.
Do you agree with these terms?