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Email
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Phone
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Company
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Job Title
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Business Address
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City
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Postal/Zip Code
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I am a:
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Hearing Instrument Specialist
Board Certified Hearing Instrument Specialist
Clinical Audiologist
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License #
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Do you hold, or have you ever held a license to fit and dispense hearing aids in multiple states?
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Yes
No
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If yes, which states?
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License #s
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Please answer yes or no
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No
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If yes, provide a complete explanation
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Have you ever been convicted of a misdemeanor (traffic violations not included) or a felony?
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No
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If yes, provide a complete explanation.
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Please select yes or no
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Date
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February
2026
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