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P.O. Box 71604 |
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I am applying for: | _______ Regular Membership ($125.00) | _______ Associate Membership ($65.00) |
Name: ___________________________________________________ | State Cert. #__________________________ |
Company: ________________________________________________________________________________________ |
IA H/A License # __________________________________ | IA Aud License # ________________________________ |
Business Address: _________________________________________________________________________________ |
Business City: ___________________________________ | Business State: ________ | Business Zip: __________ |
Business Phone: _________________________________ | Business Fax: ___________________________________ |
Email Address: ____________________________________________________________________________________ |
Home Address: ____________________________________________________________________________________ |
Home City: ______________________________________ | Home State: ___________ | Home Zip: _____________ |
Home Phone: ____________________________________________________________ |
Mailing Preference: | __________ Business Address | __________ Home Address |
If you are a temporary certificate holder, please indicate the expiration date: ______________________________________ |
Are you a member of the International Hearing Society? | __________ Yes | __________ No |
Referred by: _______________________________________________________________________________________ |
I hereby apply for
membership in the Iowa Hearing Association and if accepted, I hereby
subscribe to the Code of Ethics of the Association. Signature: ________________________________________________________________________________________ |
Enclosed is my check
for $___________________ made payable to: Iowa Hearing Association - P.O. Box 71604 - Clive, IA 50325 |
Questions, please email: APMSTHOMAS@aol.com |