Form

Address *

Work Number *

- Area Code Phone Number
Cell Number

- Area Code Phone Number
Fax Number

- 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:

Regular Member (Licensed Hearing Instrument Specialist or Audiologist) $ 125.00

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
Should be Empty:

Membership Application / Renewal Form