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Welcome Miracle-Ear Professionals!
Annual Membership Renewal
Through Dec 31, 2018

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.

This membership form is for Miracle-Ear Professional Members only. If you are not licensed, you may choose the Associate/Affiliate or Student category. Please use this form to renew your IHS Associate or Student memberships.

***************** IMPORTANT ******************

While your Professional Membership is complimentary through the Miracle-Ear membership program, you must still opt in and "renew" every year. This tells us that you still wish to be a member. All renewals are due to IHS by December 31, 2017 for the 2018 year.

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* Required Info

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 *

Franchise Account Number *

Franchise Owner Name *

I am... *
an Employee
the Franchise Owner

Number of offices:

Number of dispensers:

Address line 1 *

Address line 2

City *

State/Province *

Zip/Postal Code *

Country *

Phone *

Fax

Email (for Listing) *

Website

Preferred Mailing Address *
Business
Home


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


Do you train apprentices?
Yes
No


If you are Retired, what date did you retire?


Professional Info

Which title best describes you? *
Audiology Assistant
Audiologist
Consultant (Not a Dispenser)
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 (Optional)

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

Other Amount for Advocacy Alliance Contribution



Payment Method for Advocacy Contribution

Please choose your method of payment:
Visa
MasterCard
American Express
Discover

Name on Card

Card Number

Expiration Date

Security Code


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