Complete this application to begin your 2017 membership!
If you are not yet licensed, you may qualify for the student or association/affiliate membership. Please use this form.
If you have a promo code, enter it below. Staff will check validity of promo code upon receiving your application:
* Required Info
Name (First, Middle, Last) *
Date of Birth (mm/dd/yy) *
Last Four Digits of SS/SI Number *
Zip/Postal Code *
Franchise/Company Name *
Franchise Account Number *
Franchise Owner Name *
I am... *
the Franchise Owner
Number of offices:
Number of dispensers:
Address line 1 *
Address line 2
Email (for Directory and IHS Contact) *
Preferred Mailing Address *
Are you a military veteran?
If you are a veteran, in which branch did you serve?
Do you train apprentices?
If you are Retired, what date did you retire?
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
If you have chosen to contribute to IHS Advocacy Alliance, please choose your method of payment (optional):
Name on Card
I agree to abide by the Bylaws and Code of Ethics of the International Hearing Society.
Do you agree with these terms?