fv-2022 Installment/Auto-Renew Renewal Form

Thank you for joining IHS!

This form is for Professional Members (US and International) who wish to utilize an Installment Payment Plan to pay for their 2022 membership fees, or who would like to sign up for auto-renew. If you are not a hearing aid dispenser (Professional Member), please use this form instead.

Payment by credit card will complete your renewal at the end of this form. The work IHS does is only possible because of the dedication and loyalty of our sustaining members – we appreciate you!

IHS Membership runs on the calendar year. This form allows you to renew your membership from 1/1/2022 - 12/31/2022.

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, 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 / 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) *

What prompted you to join IHS? *

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

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 Other or Prefer Not to Answer

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.

Do you have a promo code?

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 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 *

I acknowledge and agree to the above statement.

By submission of this form, you are authorizing the International Hearing Society to charge your credit card according to the plan you choose below. *

I acknowledge and agree to the above statement.

Please Choose Your Membership Category and Plan Below.

Important Notes - $10 Admin Fee Is Waived for 2022

The quarterly installment plan will charge your credit card every three months on the same day you initiated payments, until the total amount is paid by the last quarter.

The monthly plan will charge your card each month on the same day you initiated payments, until the total amount is paid by the last month in the year.

The annual auto renewal plan is available to Professional members (US and International) and will charge your card the full amount for this year, and going forward every year until you tell us to stop the auto-renew, or the credit card becomes unavailable for use (expired card, declined, etc.)

All installment payment fees will be be paid no later than the end of December 2022 for the current membership year and charged in US currency. We will contact you if a card is declined or expired to obtain a new payment method so that your membership can continue uninterrupted.

Please contact your IHS Membership Team if you have any questions at 734.522.7200, option 3, or membership@ihsinfo.org.

Your Membership Category Choices:

Professional - US: Individuals engaged in the practice of testing human hearing and selecting fitting, counseling patients and dispensing hearing instruments. If you are licensed, you should choose this category.
Professional - International: Those professionals employed outside the United States.

Choose Your Membership Category and Plan (fees shown in US currency): *

US Professional Quarterly Installment ( $ 81.25 for each three months )

US Professional Monthly Installment ( $ 27.08 for each month )

US Professional ANNUAL AUTO RENEW ( $ 325.00 for each year )

Charges your card automatically next year unless the card is no longer active, until you cancel.

Int'l Professional Quarterly Installment ( $ 33.75 for each three months )

Int'l Professional Member Monthly Installment ( $ 11.25 for each month )

Int'l Professional ANNUAL AUTO RENEW ( $ 135.00 for each year )

Charges your card automatically next year unless the card is longer active, until you cancel.

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

2022 IHS Membership Application Form