Dues Payment Form
Full Name
*
First Name
Last Name
Professional Designation (BC-HIS, ACA, MA, etc)
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Please enter a valid phone number.
Personal Email
*
example@example.com
Dues - Please select for your Membership Type
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Provider
$
125.00
Provisional, Associate, Student, Audiologist, Professor/Education Audiologist, ENT/Physician, Manufacturer/Vendor, Consultant, Hearing Aid Tech, Office Staff, Non-dispensing owner, Other
$
62.50
Terms and Conditions
I agree to abide by the Bylaws and Code of Ethics of the Colorado Hearing Society.
Signature
*
Date
*
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Month
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Day
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Date
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