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Joint IHS/CHIPS Member Application

Complete this application to begin your 2017 membership!

All memberships run on a calendar year, so your membership will be valid until Dec. 31, 2017.

Payment by credit card, processed in US currency, will complete your application at the end of this form.

Your IHS/CHIPS joint membership will be processed in US currency (USD). Should you choose not to use this form for online payment, please submit your bank draft payable in US CURRENCY, to the International Hearing Society, 16880 Middlebelt Rd., Ste. 4, Livonia, MI 48154 USA. PERSONAL CHEQUES AND ANY CHEQUE THAT IS NOT A BANK DRAFT WILL NOT BE ACCEPTED.

The work IHS and CHIPS does is only possible because of the dedication and loyalty of our sustaining members – we appreciate you!

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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.
Industrial: Individuals engaged in the hearing aid industry, but not necessarily involved in all phases of the practice of testing human hearing and selecting, fitting and/or counseling and dispensing hearing instruments.
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.

 

All amounts are in US currency.

Membership Type
$244 USD - Professional (U.S.)
$100 USD - Industrial
$100 USD - Affiliate/Associate
$40 USD - Student


Promo Code

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


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?
No

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


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
High School
Some College or Trade School
College Graduate
Post Graduate

Institution and Degree

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. Your donation will be processed in US currency.


$25
$50
$100
$250

Other Amount - please specify below


Terms and Conditions

I agree that my membership payment will be processed in US currency (USD). 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