NHS Membership Application

Nebraska Hearing Society Membership Application Form

ALL SECTIONS ARE REQUIRED FOR MEMBERSHIP*
Name*

First NameLast NameSuffix
Company*
Position with Company*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Telephone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Business email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Last 4 digits of SS*
I am applying for:*
prevnext( X )
New Membership
$90.00



Renewal of Membership
$90.00



Associate Membership
$35.00



Affiliate Membership
$250.00



Industrial Membership
$600.00



Total

$0.00
I am a:*

Hearing Instrument SpecialistBoard Certified Hearing Instrument SpecialistClinical AudiologistOther
License #
Do you presently hold, or have you ever held a license to fit and dispense hearing aids in states other than Nebraska?*

YesNo
If yes, which states?
License numbers
Ex. 12345, 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*
Date*

MonthDayYear
Date
Should be Empty:

Nebraska Hearing Society Membership Application Form