Colorado Hearing Society

Application for Membership - 2009

 

(Please print)

Name (Last, First, Middle): ______________________________________________________________

Home Address: _____________________________________________________________________

                        ______________________________________________________________________

Home Phone: _______________________________________________________________________

Email: ____________________________________________________________________________

Date of Birth: _________________________ Social Security Number:  ________________________

Business Name: ________________________________Business Phone:_________________________

Business Address: ___________________________________________________________________

                              ___________________________________________________________________

Business Title:  _____________________________________________________________________

Duties: ___________________________________________________________________________

 

Have you ever had a hearing instrument license revoked? (Circle one)                                Yes     No

          If yes, what state?  ___________________________________________

Are you a member in good standing of the International Hearing Society?  (Circle one)            Yes     No

Are you Board Certified in Hearing Instrument Sciences?  (Circle one)                               Yes     No

List any state Hearing Society of which you are a member:  ___________________

Do you have any other professional designations, experience or qualifications to

          dispense hearing instruments?  If yes, please summarize _______________              Yes    No

          ____________________________________________________________

 

Please list your two previous employers:

 

Company: _______________________________   Phone Number: _____________________________________

Company Address:  ___________________________________________________________________________

                      ___________________________________________________________________________

Contact Person:  _____________________________________________________________________________

Dates Employed:  ____________________________________________________________________________

 

Company: _______________________________   Phone Number: _____________________________________

Company Address:  ___________________________________________________________________________

                      ___________________________________________________________________________

Contact Person:  _____________________________________________________________________________

Dates Employed:  ____________________________________________________________________________

 

Continuing Education:

Please list any continuing education classes you have attended the past two years:

Class:  _________________________________   Sponsor: __________________________________________

Date:  _________________________________   Credits:  __________________________________________

 

Class:  _________________________________   Sponsor: __________________________________________

Date:  _________________________________   Credits:  __________________________________________

 

 

Applicant's signature ___________________________________  Date: ________________________________

 

Please mail completed application with a check made payable to The Colorado Hearing Society for $100

(annual dues of $75 plus $25 initiation fee) to:

 

Connie Patton    3100 Remington Street    Fort Collins, CO. 80525

970-223-2991    email: thehearingctr@comcast.net

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