2025 Membership Application/Renewal Form -pay by check

2025 Membership Application/Renewal Form - Pay By Check

The only professional trade group representing hearing instrument dispensers in Illinois.
Choose one:*

I am a new memberI am renewing my membershipI am renewing an organizational membership
Name*

First NameLast Name
Last 4 digits of SSN (for CE)*
Professional Credentials:*
Company Name*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone #*
Please enter a valid phone number.
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal/Cell #
Please enter a valid phone number.
Email*
example@example.com
Website
Membership Type:*

1-Year Regular Member - $195.001-Year Associate Member - $195.00
1-year Organizational Membership | Call for quote if membership is different from last year.
Check #*
Please Send Check to:

Illinois Hearing Society

1 N Old State Capitol Plaza, Suite 410

Springfield, IL 62701-1368
*I agree to abide by the bylaws of the Illinois Hearing Society, the International Hearing Society Code of Ethics and any applicable federal & state laws. (By signing, you agree to abide by the above qualifications and acknowledge you are the applicant)

Clear
Should be Empty:

2025 Membership Application/Renewal Form - Pay By Check