Oregon Chapter Membership Application 2024

Thank you for your interest in joining the Oregon Hearing Society. Membership for 2024 is free for all qualified applicants. We are excited about rebuilding our society and looking forward to having you as part of our community.
Membership Application
Name*

First NameMiddle InitialLast Name
Personal Information
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Number

Area CodePhone Number
Cell Number

Area CodePhone Number
Personal E-mail*
Business Information
Name & Title
Business Name*
Business Address*

Street Address

Street Address Line 2

CityState

Zip Code
Business Number*

Area CodePhone Number
Business Email
example@example.com
Website
Other Address (fill in here)
Birthdate
What is your Preferred Mailing Address?*

PersonalBusinessOther
Are you licensed in the state of Oregon?

YesNo
License #
Are you licensed in another state?

YesNo
List States and License #s
Are you NBC-HIS?

YesNo
Member of IHS?

YesNo
Membership Levels

Membership Year is January 1 through December 31 and is free for 2024 year only.
- Regular Membership - Voting privileges / for person having a valid Oregon dispenser's license)
- Associate Membership - No voting privileges / for temporary licensee of Oregon or any person with a vested interest)
- Trainee/Temp Membership - No voting privileges
Type of Membership
What do you feel OHS's top 3 priorities should be?
New Applicant Affidavit

I agree to abide by the Bylaws of this Society, by all regulations and policies established by the Corporate Board and the code of Ethical Trade practices for the Hearing Aid Industry. I also understand that failure to do so may result in the cancellation and recall of my membership and expulsion from the Society

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