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Welcome Miracle-Ear Professional!
New Member Application

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.


Promo Code

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

* 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

Franchise/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 Directory and IHS Contact) *

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
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


Advocacy Payment Method

If you have chosen to contribute to IHS Advocacy Alliance, please choose your method of payment (optional):
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