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
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.

My Products*

NHS Members Includes NHS annual membership fee and CE classes with food

$290.00 Quantity

Non-NHS MembersIncludes CE classes with food only, no NHS membership

$330.00 Quantity

NHS Board Members and Lifetime MembersIncludes NHS annual membership fee and CE classes with food

$200.00 Quantity

Non-Licensed ObserverIncludes food, may be present during CE class but no CE credit given

$100.00 Quantity

Extra Lunch TicketIncludes lunch meal only, may not be present during CE class

$25.00 Quantity

Manufacturer TableIncludes table and food during NHS annual seminar

$420.00 Quantity

Total

$0.00

Credit Card

Should be Empty:

2025 Event Registration & Membership Form

Event Registration Information

Membership Information

Payment

Credit Card