Georgia Chapter New Member App

New Member Application
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Business Name*
Georgia Dealer's License #*
Georgia Dispenser's License Number*
Georgia Apprentice's Permit Number*
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Street Address

Street Address Line 2

CityState

Zip Code
Work Number*

Area CodePhone Number
E-mail*
If accepted in the Society, I agree to abide by the By Laws of the Georgia Society of Hearing Professionals, the Code of Ethics published by the International Hearing Society, the Federal Trade Commission Trade Practice Rules for the Hearing Aid Industry and the Rules for the Hearing Aid Industry published by the Food and Drug Administration.
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1-Year Voting Membership$120.00

Total $0.00
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New Member Application