OHADA Membership Application
Name
*
First Name
Last Name
Company
*
If none, type "none"
Company Website
*
If none, type "none"
Company Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Main Phone Number
*
Office/Cell, Please enter a valid phone number.
Secondary Phone Number
Office/Cell, Please enter a valid phone number.
Email
*
example@example.com
Role:
*
Hearing Instrument Specialist
Audiologist
Student
Other
Oklahoma License Number
*
Last four digits of your social security number
*
Please enter a number from 0 to 9999. Just the last four please, required for CEU tracking.
Registration Type
*
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( X )
Membership & Live Attendance
$
250.00
Quantity
1
2
3
4
5
6
7
8
9
10
Membership & Virtual Attendance
$
300.00
Quantity
1
2
3
4
5
6
7
8
9
10
Membership Only
$
150.00
Quantity
1
2
3
4
5
6
7
8
9
10
I am registering for more than one person
*
Yes
No
Please provide information for all additional regstrants
Continue to payment
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