2022 IHS Canada Membership Application Form

Thank you for applying for membership!

IHS membership runs on the calendar year. This form allows you to join for 1/1/2022 - 12/31/2022.

Would you like to pay by installment plan or set up yearly auto-renew?

Please use this form to set up your installment plan or auto-renew.

If you have any questions about your membership or this form, please email us at membership@ihsinfo.org, or call us at 734.522.7200, option 2, for Membership Staff to assist you.

Name *

First Name Middle Name Last Name

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

Company/Business Name

Company/Business Address:

Street Address

Street Address Line 2

City State

Zip Code Country

Home Address: *

Street Address

Street Address Line 2

City State

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 SI number (used only to match you in the database) *

What prompted you to join the Society? *

What is the single most important thing you need solved in your business or career today?

What is the most important takeaway you need from your IHS membership?

Are you *

A business owner An employee

Please choose the type of location at which you work

Retail or Manufacturer Owned Independently Owned Franchise Hospital or Medical Office Educational Institution

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

Birth Date - We love to send birthday cards!

Month Day Year

In what states or provinces are you licensed or otherwise authorized to dispense hearing aids? Please list the state/province and your registration number, if applicable. *

If you are not a practicing hearing instrument specialist, please type "Not Applicable" 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.

Do you have a membership promo or referral code? If so, please enter it below:

You're almost done! 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. *

I acknowledge and agree to the above statement.

By submission of this form, you are providing your express consent that the International Hearing Society may retain your information in our databases 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. *

I acknowledge and agree to the above statement.

Your Membership Category Choices:

Professional International : Individuals engaged in the practice of testing human hearing and selecting, fitting and dispensing hearing instruments, and counseling clients.
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.
Inactive (Fully Retired Only) : Individuals who are fully retired from the profession and no longer working or practicing.

Choose one Membership Category (fees shown in US currency):

Professional International $ 135.00

Affiliate/Associate $ 55.00

Student $ 40.00

Inactive (Fully Retired Only) $ 35.00

Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country