1001 Office Park Road, Suite 105
West Des Moines, Iowa  50265
Phone/Fax:  515-440-6057


  • PLEASE PRINT OUT AND RETURN THIS FORM TO APPLY FOR IHA MEMBERSHIP

  • PLEASE LIST INFORMATION EXACTLY AS DESIRED IN THE DIRECTORY

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    -  1001 Office Park Road, Suite 105  -   West Des Moines, IA  50265
Questions, please email:  APMSTHOMAS@aol.com