PRINT THIS PAGE, FILL OUT AND FAX TO US AT 573-636-9749
MISSOURI HEARING SOCIETY
101 E. High • P.O. Box 1072 • Jefferson City, Missouri 65102 • 573/636-2822
MEMBERSHIP APPLICATION
(Please Print or Type)
Name: ______________________________________ Date: ____________
Name of Business: ______________________________________________
Business Address: ___________________________________
City: ______________State: _____ Zip: _________
Phone: ____________ Fax:_____________ E-Mail: __________________
Home Address: ____________________________________ City: ________________
State: _____ Zip: _________ Phone: ____________ Cell:_______________
Type of Membership Applying For:
Regular Member - $125.00
(Missouri Licensed Hearing Instrument Specialist or Audiologist)
Associate Member - $50.00
If you wish to pay by credit card you may fax your info to (573) 636-9749 or mail to the MHS Office. VISA or MASTERCARD Charge Card No. ________________________
Name of Card Holder: _______________________________ Expiration Date: _________
Do You Hold: Valid Permanent MO Hearing Instrument Specialist License? ____
Valid Permanent MO Audiologist License? _____
License # ____________ Date(s) Received: _____________
Temporary Permit? ____ Permit # ___________ Date Received: _______
Do you or have you ever held a Hearing Instrument Specialist or Audiologist License from another State?
Yes State(s): ______________________________________
Valid Invalid Revoked
No
Have you ever been a member of MHS before? o Yes o No
Are you NBC-HIS? _______ CCC-A? __________ Au.D? __________
List other associations you belong to: ____________________________________________
____________________________________________
MO Legislative Districts: Home - _____ House _____ Senate
Office - _____ House _____ Senate
I hereby 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.
________________________________________________________________
SIGNATURE DATE APPROVED BY BOARD
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SPONSORED BY (OPTIONAL)