Membership Application
Full Name
*
First Name
Middle Name
Last Name
Month and Date of Birth (year is optional)
How would you like your name to be shown in our directory?
Professional Designation (BC-HIS, ACA, MA, etc)
*
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (home)
Please enter a valid phone number.
Phone Number (cell)
Please enter a valid phone number.
Personal Email
*
example@example.com
Professional Information
I am:
An employee
Business owner
If owner, number of offices in Colorado:
Business Name
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Phone Number
Please enter a valid phone number.
Business Email
example@example.com
Website
What is your preferred mailing address?
Home
Business
Which titles best describe you?
Provider
Hearing Aid Tech
Audiologist
Audiology Assistant
ENT/Physician
Manufacturer/Vendor
Office Staff
Professor/Education Audiologist
Provisional/Associate/Student
Owner
Other
I am licensed/qualified to dispense hearing instruments in the following states/provinces/countries:
My License/Registration Number is:
I began dispensing hearing instruments in (year):
I am currently a student, (show program and anticipated licensing date):
Membership Type
prev
next
( X )
Provider
$
125.00
Quantity
1
2
3
4
5
6
7
8
9
10
Provisional, Associate, Student, Audiologist, Professor/Education Audiologist, ENT/Physician, Manufacturer/Vendor, Consultant, Hearing Aid Tech, Office Staff, Non-dispensing owner, Other
$
62.50
Quantity
1
2
3
4
5
6
7
8
9
10
Terms and Conditions
I agree to abide by the Bylaws and Code of Ethics of the Colorado Hearing Society.
Signature
Date
-
Month
-
Day
Year
Date
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