
	1001 Office Park Road, Suite 105 West Des Moines, Iowa 50265 Phone: 515-440-6057 Fax: 515-440-6055

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