NHS Conference Registration 2022

2023 Event Registration & Membership Form

Nebraska Hearing Society
Event Registration Information
Full Name*

First NameLast NameSuffix
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Personal E-mail*
example@example.com
Personal Phone Number*
Last 4 digits of SSN*
Membership Information

ALL SECTIONS ARE REQUIRED FOR MEMBERSHIP *
Company
Position with Company
Business Telephone Number
Please enter a valid phone number.
Business Email
example@example.com
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I am a:

Hearing Instrument SpecialistBoard Certified Hearing Instrument SpecialistClinical AudiologistOther
If "other" selected above, please specify:
License Number (NE)
Do you presently hold, or have you ever held a license to fit and dispense hearing aids in states other than Nebraska?

YesNo
Is yes, which states?
License numbers (other states)
Separate numbers with commas (Ex. 12345, 12345)
Have you ever had your license revoked or suspended or been the subject of any hearings related to the practice of dispensing hearing aids in this state or any other state?

YesNo
If yes, provide a complete explanation.
Have you ever been convicted of a misdemeanor (traffic violations not included) or a felony?

YesNo
If yes, provide a complete explanation.
If accepted for membership into the Nebraska Hearing Society, I will abide by the Code of Ethics and By-Laws of the Society, including the FTC Trade Practice rules for the Hearing Aid Industry.
Signature*

Clear
Date*

MonthDayYear
Date
Payment

Please select all that apply.
Scroll through the whole list to find which options suit your preference for registration. *
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MEMBER - Event Registration ONLYIncludes CE Credits* & 2023 NHS Membership*All fees must be received no later than April 20th, 2023, to ensure credit hours are awarded for attendance, no exceptions. Paypal and paper options are both acceptable.
$200.00 Quantity



NON-MEMBER - Event Registration ONLYIncludes CE Credits**All fees must be received no later than April 20th, 2023, to ensure credit hours are awarded for attendance, no exceptions. Paypal and paper options are both acceptable.
$330.00 Quantity



NHS Board Member - Event Registration ONLY
$200.00 Quantity



NHS Lifetime Member - Event Registration ONLY
$200.00 Quantity



2023 Vendor Exhibitor Fee - Event Registration ONLY*Exhibitor Fee must be received no later than April 1st, 2023. Please contact Janie York at janie@hearnowsolutions.com with questions. Thank you for supporting The Nebraska Hearing Society.
$420.00 Quantity



NEW MEMBER - Membership Reg ONLY
$90.00



MEMBER RENEWAL - Membership Reg ONLY
$90.00 Quantity



ASSOCIATE MEMBER - Membership Reg ONLY
$35.00 Quantity



AFFILIATE MEMBER - Membership Reg ONLY
$250.00 Quantity



INDUSTRIAL MEMBER - Membership Reg ONLY
$600.00 Quantity



Total

$0.00
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