Membership Application / Renewal Form
Choose one
*
I am renewing my membership
I am a new member
Name
*
First Name
Last Name
Name of Business
*
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Work Number
*
-
Area Code
Phone Number
Cell Number
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Area Code
Phone Number
Fax Number
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Area Code
Phone Number
E-mail
*
Do you hold a valid permanent Hearing Instrument Specialist License?
*
Yes
No
Do you hold a valid permanent Audiologist License?
*
Yes
No
If yes to either question above, what is the license number?
*
Date you received your license:
Is this a temporary permit?
Yes
No
If a temporary permit, what is the Permit #?
Date you received your permit:
Do you now or have you ever held a Hearing Instrument Specialist or Audiologist License from another State?
*
Yes
No
If yes to the above, list state(s)
Status of license from another state(s)
Valid
Invalid
Revoked
Choose all that apply:
NBC -HIS
CCC-A
AuD
Do you agree to abide by the Laws of the State of Missouri governing the fitting and dispensing of hearing instruments and to comply with MHS' Standards of Conduct?
*
Yes
Membership Options:
*
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Regular Member (Licensed Hearing Instrument Specialist or Audiologist)
$
130.00
Associate Member (Provider of goods and services to a Licensed Hearing Instrument Specialist or Audiologist)
$
50.00
Individual member (Non-Licensed - Any person in consonance with the purpose and goals of the Society who is not eligible to be a Regular or Associate Member)
$
50.00
Click to add payment
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