Membership Registration Form

If you wish to pay by check instead of using a credit card, please print and fill out this form and make check payable to Hearing Healthcare Alliance of Ohio. Mail to: Joe Rosengarten, Treasurer, 6601 Taywood Drive, Englewood, OH 45322-3761

Name

First NameMiddle NameLast Name

Please choose one:

Birth Date:

MonthDayYear

Ohio License Number:

Business Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Business Phone Number:

Area CodePhone Number

Business Fax Number:

Area CodePhone Number

Business E-mail

Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone Number:

Area CodePhone Number

Home Email:

example@example.com

Please list the address on the Alliance Website:

Are you a member of:

Are you Board Certified by:

Are you an Audioprosthologist?

Are you a Hearing Instrument Specialist?

Are you a licensed Audiologist?

I am a:

Level of Education (check one):

The Hearing Healthcare Alliance of Ohio Code of Ethics will be included with your membership card. By signing below, your signature confirms you agree to adhere to the Hearing Healthcare Alliance of Ohio Code of Ethics.

Signature

My Products

Full Membership$150.00

FULL MEMBER - A Hearing Instrument Specialist or Audiologist who is engaged in or is employed by an individual, partnership or corporation engaged in the selecting, selling, fitting and servicing of hearing aids and accessories on a retail level, and maintains an established place of business, and who meets qualifications to render properly these services as set forth in the By-laws of this Alliance, may be eligible to become a Full Member of this Alliance

Associate Member$75.00

ASSOCIATE MEMBER - (Non-licensed office staff personnel, a hearing instrument specialist trainee not yet licensed under ORC 4747.05. An audiology student who is not yet licensed under ORC 4753.06. Such Associate Member shall have no voting privileges nor hold office, but may serve on committees of the Alliance.)

Sustaining Member$50.00

SUSTAINING MEMBER - An individual or company that embraces the intent and spirit of the Hearing Healthcare Alliance of Ohio and who wishes to financially support the organization. Such members shall have no voting privileges nor hold office.

Total $0.00

Membership Application

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