2024 Membership Application/Renewal Form -pay by check

2024 Membership Application/Renewal Form - Pay by Check

The only professional trade group representing hearing instrument dispensers in Illinois.
Choose one:

I am a new memberI am renewing my membershipI am renewing an organizational membership
Name*

First NameLast Name
Last 4 digits of SSN (for CE)*
Professional Credentials:*
Company Name*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone #*
Please enter a valid phone number.
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal/Cell #*
Please enter a valid phone number.
Website
Membership Level*

1-year Regular Membership $195.001-year Associate Membership $195.001-year Organizational Membership - call for quote if membership is different from last year.
Please Send Check to:

Illinois Hearing Society

1 N Old State Capitol Plaza, Suite 410

Springfield, IL 62701-1368
*I agree to abide by the bylaws of the Illinois Hearing Society, the International Hearing Society Code of Ethics and any applicable federal & state laws. (By signing, you agree to abide by the above qualifications and acknowledge you are the applicant)

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2024 Membership Application/Renewal Form - Pay by Check