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Clear values
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User ID
is
*
First name
contains
is
does not contain
is not
empty
not empty
begins with
ends with
*
Last name
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does not contain
is not
empty
not empty
begins with
ends with
*
Email
contains
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does not contain
is not
empty
not empty
begins with
ends with
*
Phone
contains
is
does not contain
is not
empty
not empty
begins with
ends with
*
Name of Business
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is
does not contain
is not
empty
not empty
begins with
ends with
*
Work Phone
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is
does not contain
is not
empty
not empty
begins with
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*
Fax Number
contains
is
does not contain
is not
empty
not empty
begins with
ends with
*
Do you hold a valid permanent Hearing Instrument Specialist License?
is
is not
Yes
No
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Do you hold a valid permanent Audiologist License?
is
is not
Yes
No
*
If yes to either question above, what is your license number?
contains
is
does not contain
is not
empty
not empty
begins with
ends with
*
*
Date you received your license
on or before
is
on or after
empty
any date
this month
this year
last month
last year
next month
next year
is not
February
2026
*
Is this a temporary permit?
is
is not
Yes
No
*
If a temporary permit, what is the permit number?
contains
is
does not contain
is not
empty
not empty
begins with
ends with
*
*
Date you received your permit
on or before
is
on or after
empty
any date
this month
this year
last month
last year
next month
next year
is not
*
Do you/have you ever held a Hearing Instrument Specialist or Audiologist License from another state?
is
is not
Yes
No
*
If yes to the above, please select the state
is
is not
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*
Status of license from other state
is
is not
Valid
Invalid
Revoked
*
Choose all that apply
any of selected
all of selected
none of selected
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