2025 Membership Application for Dispensing Members

2026 Membership Application for Dispensing Members

January 1, 2026 - December 31, 2026
Dispensing Member:

Also known as a "Hearing Aid Dispenser" and/or "Dispensing Audiologist", is any individual engaged in the fitting, renting, selling and/or servicing of hearing instruments, hearing amplification devices, and/or accessories to the public. Such individual must be registered as a hearing aid dispenser with the State of NY pursuant to Article 37A of the General Business Law of the State of NY, or such other applicable statutes or regulation of the State of NY as may be enacted or may be in force governing the dispensing of hearing instruments in the State of NY.

Application for membership as a Dispensing Member must include evidence of an active registration with the NYS Secretary of State pursuant to Article 37A of the General Business Law (ID # and Exp Date) and identify the entity of business through which said individual is dispensing.

Full Voting Membership in the Hearing Health Care Alliance of New York, Inc. is open to all current HHCANY dispensing members who are actively registered as a Hearing Aid Dispenser by NYS.
Full Name*

First NameLast Name
NYS Registration #:
Expiration Date:
Business Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
NYS Registration/License(s):

DispenserAudiologistOther
Other Association Memberships

IHSNYSHLAAAAASHAADAOther
Professional Degrees or Certifications:

M.S.M.A.Ph.DAu.DBC-HIS*ACACCC-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 identify legislators who have HHCANY constituents.

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

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

New Members and Renewing 2025 Members
$300 for my 2026 Dispensing Member HHCANY Dues *
$300
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. for dues; and HHCANY PAC for PAC donations) to our
NEW ADDRESS:

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

Payments by Credit Card

Please FILL OUT AND SUBMIT THIS FORM using the Submit Button Below, and GO TO THE ONLINE STORE AT OUR WEBSITE: WWW.HHCANY.ORG to make your payment.

*Please note the prices to pay by check vs. payments by credit card*
Email: hhcany@hhcany.org

Phone: 518-949-7121
Should be Empty:

2026 Membership Application for Dispensing Members

Who Are Your NYS Legislators?

2026 HHCANY Membership Dues and Voluntary PAC Contribution