OHAA Membership Form

OHADA MEMBERSHIP FORM

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Personal Information
*Required fields - errors will occur if these fields are not filled out properly.
Name*
First Last
Email*

Please enter your valid email address so that we can send you confirmation of your registration.
Company Name
Website
Would you like to add a link to your company's website to your membership listing on the OHAA website for $25 per year?*
- Yes, please add my website link as shown above, to the OHAA member page.
- No, I do not want to add my website to the OHAA member page at this time.
For $25 a year, we will add a link to your company website to the OHAA member page, along with your contact information. This will increase traffic to your site and can also increase your website's search engine ranking with the inbound linking.
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Please check all that apply:
- Hearing Instrument Specialist
- Audiologist
- Other
If other please explain:
OHAA Membership/Conference Options - Please select one of the following.*
- New OHAA Membership ONLY – NOT attending conference - $100
- Renewing OHAA Membership ONLY - NOT attending conference - $100
New Member Information
This information is required only if you are applying for a NEW OHAA membership this year and have not been a member in a previous year. If you have been a member before, please go back up to the "Membership/Conference Options" and select the "Renewing" OHAA membership option you desire. Thank you.
If accepted for membership in the Oklahoma Hearing Aid Association, you are required to abide by the By-Laws and Code of Ethics of the Association. By filling out this information and paying for the membership you are agreeing to this requirement.
Position with Company:
Company Address
Street Address Address Line 2 City State ZIP Code
How long have you held a license to fit and dispense hearing aids in the State of Oklahoma?*
Do you presently hold or have you ever held, a license to fit and dispense hearing aids in states other than Oklahoma?*
- Yes - I presently hold or have held, a license to fit and dispense hearing aids in states other than Oklahoma
- No - I have NOT held a license to fit and dispense hearing aids in states other than Oklahoma
If yes, which states?
- Alabama
- Alaska
- Arizona
- Arkansas
- California
- Colorado
- Connecticut
- Delaware
- District of Columbia
- Florida
- Georgia
- Hawaii
- Idaho
- Illinois
- Indiana
- Iowa
- Kansas
- Kentucky
- Louisiana
- Maine
- Maryland
- Massachusetts
- Michigan
- Minnesota
- Mississippi
- Missouri
- Montana
- Nebraska
- Nevada
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Ohio
- Oklahoma
- Oregon
- Pennsylvania
- Rhode Island
- South Carolina
- South Dakota
- Tennessee
- Texas
- Utah
- Vermont
- Virginia
- Washington
- West Virginia
- Wisconsin
- Wyoming
Select all that apply.
License numbers:*
Have you ever had your license revoked or suspended or been the subject of any hearings related to the practice of dispensing hearing aids in this state or any other state?*
- Yes - I have had my license revoked or suspended or I have been the subject of hearings related to the practice of dispensing hearing aids in this state or another state.
- No - I have had no action against my license in this state or any other.
If you answered yes to the previous question, please give a complete explanation below:*
Have you ever been convicted of a misdemeanor (traffic violations not included) or of a felony?*
- Yes - I have been convicted of a misdemeanor or of a felony.
- No - I have not been convicted of a misdemeanor or of a felony.
If you answered yes to the previous question, please give a complete explanation below:*
Additional Memberships
2nd Membership:*
- Yes
- No
Would you like to add a second person to your order for membership?
2nd Membership Information
2nd Member Name*
First Last
Email for 2nd Member
Company Name for 2nd Member
Phone for 2nd Member
Address for 2nd Person*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Last four digits of the 2nd person's Social Security number.*
Please enter a number from 0000 to 9999.
Just the last four please, required for CEU tracking.
Please check all that apply for second person:
- Hearing Instrument Specialist
- Audiologist
- Other
If other please explain:
OHAA Membership - 2nd Person - Please select one of the following.
- New OHAA Membership (2nd Person) - $100
- Renewing OHAA Membership (2nd person) - $100
New Member Information for 2nd Person
This information is required only if the 2nd person is applying for a NEW OHAA membership this year and has not been a member in a previous year. If they have been a member before, please go back up to the "Membership/Conference Options" and select the "Renewing" OHAA membership option you desire. Thank you.
2nd Person's Position with Company:
Company Address for 2nd Person
Street Address Address Line 2 City State ZIP Code
How long has the 2nd person held a license to fit and dispense hearing aids in the State of Oklahoma?*
Does the 2nd person presently hold or have they ever held, a license to fit and dispense hearing aids in states other than Oklahoma?*
- Yes - The 2nd person presently holds or has held, a license to fit and dispense hearing aids in states other than Oklahoma
- No - The 2nd person has NOT held a license to fit and dispense hearing aids in states other than Oklahoma
If yes, which states does the 2nd person hold licenses?
- Alabama
- Alaska
- Arizona
- Arkansas
- California
- Colorado
- Connecticut
- Delaware
- District of Columbia
- Florida
- Georgia
- Hawaii
- Idaho
- Illinois
- Indiana
- Iowa
- Kansas
- Kentucky
- Louisiana
- Maine
- Maryland
- Massachusetts
- Michigan
- Minnesota
- Mississippi
- Missouri
- Montana
- Nebraska
- Nevada
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Ohio
- Oklahoma
- Oregon
- Pennsylvania
- Rhode Island
- South Carolina
- South Dakota
- Tennessee
- Texas
- Utah
- Vermont
- Virginia
- Washington
- West Virginia
- Wisconsin
- Wyoming
Select all that apply.
License numbers for 2nd person:*
Has the 2nd person ever had their license revoked or suspended or been the subject of any hearings related to the practice of dispensing hearing aids in this state or any other state?*
- Yes - the 2nd person has had their license revoked or suspended or they have been the subject of hearings related to the practice of dispensing hearing aids in this state or another state.
- No - the 2nd person has not had any action against their license in this state or any other.
If the 2nd person answered yes to the previous question, please give a complete explanation below:*
Has the 2nd person ever been convicted of a misdemeanor (traffic violations not included) or of a felony?*
- Yes - the 2nd person has been convicted of a misdemeanor or of a felony.
- No - the 2nd person has not been convicted of a misdemeanor or of a felony.
If the 2nd person answered yes to the previous question, please give a complete explanation below:*
3rd Membership:*
- Yes
- No
Would you like to add a third person to your order for membership?
3rd Membership Information
3rd Member Name*
First Last
Email for 3rd Member
Company Name for 3rd Member
Phone for 3rd Member
Address for 3rd Membership*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Last four digits of the 3rd person's Social Security number.*
Please enter a number from 0000 to 9999.
Just the last four please, required for CEU tracking.
Please check all that apply for third person:
- Hearing Instrument Specialist
- Audiologist
- Other
If other please explain:
OHAA Membership - 3rd Person - Please select one of the following.
- New OHAA Membership (3rd person) - $100
- Renewing OHAA Membership (3rd person) - $100
New Member Information for 3rd Person
This information is required only if the 3rd person is applying for a NEW OHAA membership this year and has not been a member in a previous year. If they have been a member before, please go back up to the "Membership/Conference Options" and select the "Renewing" OHAA membership option you desire. Thank you.
3rd Person's Position with Company:
Company Address for 3rd Person
Street Address Address Line 2 City State ZIP Code
How long has the 3rd person held a license to fit and dispense hearing aids in the State of Oklahoma?*
Does the 3rd person presently hold or have they ever held, a license to fit and dispense hearing aids in states other than Oklahoma?*
- Yes - The 3rd person presently holds or has held, a license to fit and dispense hearing aids in states other than Oklahoma
- No - The 3rd person has NOT held a license to fit and dispense hearing aids in states other than Oklahoma
If yes, which states does the 3rd person hold licenses?
- Alabama
- Alaska
- Arizona
- Arkansas
- California
- Colorado
- Connecticut
- Delaware
- District of Columbia
- Florida
- Georgia
- Hawaii
- Idaho
- Illinois
- Indiana
- Iowa
- Kansas
- Kentucky
- Louisiana
- Maine
- Maryland
- Massachusetts
- Michigan
- Minnesota
- Mississippi
- Missouri
- Montana
- Nebraska
- Nevada
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Ohio
- Oklahoma
- Oregon
- Pennsylvania
- Rhode Island
- South Carolina
- South Dakota
- Tennessee
- Texas
- Utah
- Vermont
- Virginia
- Washington
- West Virginia
- Wisconsin
- Wyoming
Select all that apply.
License numbers for 3rd person:*
Has the 3rd person ever had their license revoked or suspended or been the subject of any hearings related to the practice of dispensing hearing aids in this state or any other state?*
- Yes - the 3rd person has had their license revoked or suspended or they have been the subject of hearings related to the practice of dispensing hearing aids in this state or another state.
- No - the 3rd person has not had any action against their license in this state or any other.
If the 3rd person answered yes to the previous question, please give a complete explanation below:*
Has the 3rd person ever been convicted of a misdemeanor (traffic violations not included) or of a felony?*
- Yes - the 3rd person has been convicted of a misdemeanor or of a felony.
- No - the 3rd person has not been convicted of a misdemeanor or of a felony.
If the 3rd person answered yes to the previous question, please give a complete explanation below:*
4th Membership:*
- Yes
- No
Would you like to add a forth person to your order for membership?
4th Membership Information
4th Member Name*
First Last
Email for 4th Member
Company Name for 4th Member
Phone for 4th Member
Address for 4th Membership*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Last four digits of the 4th person's Social Security number.*
Please enter a number from 0000 to 9999.
Just the last four please, required for CEU tracking.
Please check all that apply for 4th person:
- Hearing Instrument Specialist
- Audiologist
- Other
If other please explain:
OHAA Membership - 4th Person - Please select one of the following.
- New OHAA Membership (4th person) - $100
- Renewing OHAA Membership (4th person) - $100
New Member Information for 4th Person
This information is required only if the 4th person is applying for a NEW OHAA membership this year and has not been a member in a previous year. If they have been a member before, please go back up to the "Membership/Conference Options" and select the "Renewing" OHAA membership option you desire. Thank you.
4th Person's Position with Company:
Company Address for 4th Person
Street Address Address Line 2 City State ZIP Code
How long has the 4th person held a license to fit and dispense hearing aids in the State of Oklahoma?*
Does the 4th person presently hold or have they ever held, a license to fit and dispense hearing aids in states other than Oklahoma?*
- Yes - The 4th person presently holds or has held, a license to fit and dispense hearing aids in states other than Oklahoma
- No - The 4th person has NOT held a license to fit and dispense hearing aids in states other than Oklahoma
If yes, which states does the 4th person hold licenses?
- Alabama
- Alaska
- Arizona
- Arkansas
- California
- Colorado
- Connecticut
- Delaware
- District of Columbia
- Florida
- Georgia
- Hawaii
- Idaho
- Illinois
- Indiana
- Iowa
- Kansas
- Kentucky
- Louisiana
- Maine
- Maryland
- Massachusetts
- Michigan
- Minnesota
- Mississippi
- Missouri
- Montana
- Nebraska
- Nevada
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Ohio
- Oklahoma
- Oregon
- Pennsylvania
- Rhode Island
- South Carolina
- South Dakota
- Tennessee
- Texas
- Utah
- Vermont
- Virginia
- Washington
- West Virginia
- Wisconsin
- Wyoming
Select all that apply.
License numbers for 4th person:*
Has the 4th person ever had their license revoked or suspended or been the subject of any hearings related to the practice of dispensing hearing aids in this state or any other state?*
- Yes - the 4th person has had their license revoked or suspended or they have been the subject of hearings related to the practice of dispensing hearing aids in this state or another state.
- No - the 4th person has not had any action against their license in this state or any other.
If the 4th person answered yes to the previous question, please give a complete explanation below:*
Has the 4th person ever been convicted of a misdemeanor (traffic violations not included) or of a felony?*
- Yes - the 4th person has been convicted of a misdemeanor or of a felony.
- No - the 4th person has not been convicted of a misdemeanor or of a felony.
If the 4th person answered yes to the previous question, please give a complete explanation below:*
Total
$0.00

To fill out a printed form and mail in click here for the PDF version.

Promoting better hearing to the Oklahoma Community!

OHAA Membership Form

OHADA MEMBERSHIP FORM

Personal Information

New Member Information

Additional Memberships

2nd Membership Information

New Member Information for 2nd Person

3rd Membership Information

New Member Information for 3rd Person

4th Membership Information

New Member Information for 4th Person

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