Directory  |  Calendar  |  Forms  |  Contact Us  |  Login

2017 Annual Membership Renewal

Thank you for helping us keep our records current to serve you better! Please complete the Contact Info section, then update us on any changes or new data you have this year.

Payment by credit card will complete your renewal at the end of this form. The work IHS does is only possible because of the dedication and loyalty of our sustaining members – we appreciate you!

********************************************

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 renew.

*********************************************

* Required information


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.
Affiliate/Associate: 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 *
$350 - Professional (U.S.) --> $325 + $25 Late Fee
$160 - Professional (International) --> $135 + $25 Late Fee
$80 - U.S. Affiliate/Associate --> $55 + $25 Late Fee
$65 - Student --> $40 + $25 Late Fee



Promo Code

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.
Yes
No

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/Info

Company Name

I am...
an Employee
the Business Owner

Number of offices:

Number of dispensers:

Do you train apprentices?
Yes
No

If you are Retired, what date did you retire?

Address line 1

Address line 2

City

State/Province

Zip/Postal Code

Country

Phone

Fax

Email *

Website

What Is Your Preferred Mailing Address?
Business
Home


Military Info

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


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):

Credentials (i.e., CCC-A, AuD):


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 and the Canadian Hearing Instrument Practitioners Society.

Do you agree with these terms?
Yes
No