2025 Membership Application for Dispensing Members

2026 Membership Application for Dispensing Member Emeritus

January 1, 2026 - December 31, 2026
Dispensing Member Emeritus: Individuals who have been a dispensing member of HHCANY, Inc. for at least 10 of the last 15 years, but are no longer actively engaged in dispensing hearing aids as defined in Section 3.01a.

Application for membership as a Dispensing Member Emeritus must include evidence of prior membership in HHCANY, and a statement from the applicant stating: I AM NO LONGER ACTIVELY ENGAGED IN DISPENSING HEARING AIDS:
Signature

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Date Signed

MonthDayYear
Date
Full Name*

First NameLast Name
Business Name:
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
E-mail*
example@example.com
IHSNYSHLAAAAASHAADAOther
M.S.M.A.Ph.DAu.DACACCC-AOther
BC-HIS: Please Indicate the Last 4 Digits of Your SS#*
Other NYS Licenses/Registrations:
Other States:
Please Indicate How You Would Like Your Name to Appear on Your Membership Certificate (include degree and accreditation, if desired)
Who Are Your NYS Legislators?
Use the links below to find your Senators and Assemblymembers where you live and work. This helps us focus our lobbying and legislative efforts on legislators who have HHCANY constituents.

https://www.nysenate.gov/find-my-senator

https://nyassembly.gov/mem/search/
Your Senator Where You Live:
Your Senator Where You Work:
Your Assemblymember Where You Live:
Your Assemblymember Where you Work:
2026 HHCANY Membership Dues and Voluntary PAC Contribution

New Members and Renewing 2025 Members
$50 for my 2026 Dispensing Member Emeritus HHCANY Dues *
$50
Voluntary Contribution to The HHCANY Political Action Committee (HHCANY PAC)
$ ___________
Our PAC is funded by member contributions, and is used to support NYS legislators and the Governor to advance our legislative agenda in Albany.
Total Amount*
$ ____________
Payment:

Please send check payments (payable to HHCANY, Inc.) to:

Hearing Health Care Alliance of New York, Inc.
130 Washington Ave.
3rd Floor North Suite A
Albany, NY 12210

Payments by Credit Card

Please SUBMIT THIS FORM (below) and got to the ONLINE STORE ON OUR WEBSITE: https://hhcany.org/store TO PAY
CheckCredit Card (Use Link Above)
Email: hhcany@hhcany.org

Phone: 518-949-7121
Should be Empty:

2026 Membership Application for Dispensing Member Emeritus

Who Are Your NYS Legislators?

2026 HHCANY Membership Dues and Voluntary PAC Contribution