2025 NHS Conference Registration

2025 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
Hearing Instrument SpecialistBoard Certified Hearing Instrument SpecialistClinical AudiologistOther
If "other" selected above, please specify:
License Number (NE)
YesNo
Is yes, which states?
License numbers (other states)
Separate numbers with commas (Ex. 12345, 12345)
YesNo
If yes, provide a complete explanation.
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.

My Products*

NHS Members

Includes NHS annual membership fee and CE classes with food

$290.00 Quantity

Non-NHS Members

Includes CE classes with food only, no NHS membership

$330.00 Quantity

NHS Board Members and Lifetime Members

Includes NHS annual membership fee and CE classes with food

$200.00 Quantity

Non-Licensed Observer

Includes food, may be present during CE class but no CE credit given

$100.00 Quantity

Extra Lunch Ticket

Includes lunch meal only, may not be present during CE class

$25.00 Quantity

Manufacturer Table

Includes table and food during NHS annual seminar

$420.00 Quantity

Total

$0.00

2025 Event Registration & Membership Form