2021 - IHS Miracle-Ear Membership Renewal Form

Thank you for renewing your membership through the IHS Miracle-Ear Membership Program!

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, 2020 for the 2021 year.

Through this special membership program, licensed Miracle-Ear professionals can become IHS members with no direct payment to IHS. If you are not a licensed professional, please use this form to apply for membership as an Affiliate/Associate or Student Member.

If you have any questions about your IHS membership or this form, please email us at membership@ihsinfo.org, or call us at 734.522.7200 and ask for Membership Staff to assist you.

Let's begin!

Are you a fully licensed consultant working for a Miracle-Ear franchise? *

Yes No

Great! Please continue with the form below. If you have any difficulty or questions while filling out the form, please let us know at membership@ihsinfo.org or 734.522.7200.

Thank you for clarifying that you are not a fully licensed consultant for a Miracle-Ear franchise. Please continue your memberhsip application using this form. If you have any questions, you may contact IHS at 734.522.7200 or membership@ihsinfo.org.

Name *

First Name Middle Name Last Name

List any credentials that apply (i.e., ACA, BC-HIS, etc.)

Company/Business Name

Franchise Account Number *

Franchise Owner Name *

I am *

An employee The franchise owner

Company/Business Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

At which address/phone would you prefer we contact you or send you mail? *

My work My home

Work Phone Number

Area Code Phone Number

Work Fax Number

Area Code Phone Number

Home Phone Number

Area Code Phone Number

Cell Phone Number *

Area Code Phone Number

Receive Text Message Updates from IHS *

Yes I'd like to receive Text Message (SMS/MMS) Member Updates from IHS! No thanks.

E-mail Address *

Website Address

Last 4 digits of SS/SI number (used only to match you in the database) *

Do you train apprentices? *

Yes No

How many offices does your company have? *

How many dispensers does your company have? *

What year did you start dispensing, if applicable? *

Please type "I am not a dispenser" if this does not apply to you

What is your highest level of education? *

What is the name of the institution where you received your highest level of education?

Are you currently enrolled in a college program? *

Yes No

Please list the institution name, program, and anticipated graduation date

Gender

Male Female

Birthdate - We love to send birthday cards!

Month Day Year

In what states or provinces are you licensed to dispense hearing aids? Please list the state and your licensing number. *

If you are not licensed, please type "Not Licensed" in the field above.

Are you a military veteran? *

Yes No

In which branch did you serve?

Which title below best describes you? *

Is this a second career for you (you've switched careers or retired from a previous profession)? *

Yes No

What was your previous profession?

Members receive The Hearing Professional magazine from IHS. Please choose your preferred method of receiving THP magazine:

I prefer to read it online only. Do not send a paper copy. I prefer to receive a paper copy in the mail.

Terms and Conditions

By completing this form you warrant that the information provided is true and accurate to the best of your knowledge. Upon IHS acceptance and processing of your application, you agree to abide by the Bylaws and Code of Ethics of the International Hearing Society. You are providing your express consent that the International Hearing Society may retain your information in our database and other data systems, and that we may contact you via any of the contact information you provided, including but not limited to email, postal mail, or phone. Our members may also be contacted by third parties such as IHS chapters, advertising or other affiliated partners from time to time. To opt out of inclusion in third-party lists, you must send your request to be excluded to interact@ihsinfo.org

Do you agree with these terms? *

Yes No

Welcome Miracle-Ear Licensed Professionals!