OHAA Membership Form OHADA MEMBERSHIP FORM Having issues with the form? Online Form Technical Support line: 918-749-2727 Hours: 10:30 am to 10:30 pm If no one answers, leave a message, we will respond as soon as possible. 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 NameWebsite 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 AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe 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 - $100Renewing OHAA Membership ONLY - NOT attending conference - $100New Member InformationThis 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 OklahomaNo - I have NOT held a license to fit and dispense hearing aids in states other than OklahomaIf 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 Memberships2nd Membership:*YesNoWould you like to add a second person to your order for membership?2nd Membership Information2nd Member Name* First Last Email for 2nd Member Company Name for 2nd MemberPhone for 2nd MemberAddress for 2nd Person* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe 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) - $100Renewing OHAA Membership (2nd person) - $100New Member Information for 2nd PersonThis 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 OklahomaNo - The 2nd person has NOT held a license to fit and dispense hearing aids in states other than OklahomaIf 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:*YesNoWould you like to add a third person to your order for membership?3rd Membership Information3rd Member Name* First Last Email for 3rd Member Company Name for 3rd MemberPhone for 3rd MemberAddress for 3rd Membership* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe 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) - $100Renewing OHAA Membership (3rd person) - $100New Member Information for 3rd PersonThis 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 OklahomaNo - The 3rd person has NOT held a license to fit and dispense hearing aids in states other than OklahomaIf 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:*YesNoWould you like to add a forth person to your order for membership?4th Membership Information4th Member Name* First Last Email for 4th Member Company Name for 4th MemberPhone for 4th MemberAddress for 4th Membership* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe 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) - $100Renewing OHAA Membership (4th person) - $100New Member Information for 4th PersonThis 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 OklahomaNo - The 4th person has NOT held a license to fit and dispense hearing aids in states other than OklahomaIf 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.