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1. Clinic or Practice Information:

Practice Name

Audiologist(s) Name and Degree(s)

Practice Address
City

State

Zip

Phone Number

Fax Number

Email Address

Website URL

2. Membership details
Price

1. Preferred Provider Community Membership (single location) $349.00

2. Add additional location $50 each

Annual Billing TOTAL

3. Payment Method

Invoice me and I will pay by check: ____________

I wish to pay by credit card: Visa: _________ Master Card: ________

Name on credit card: ____________________________

Credit card number: _____________________________

Expiration date: _____________________

I certify that I am a licensed audiologist in good standing in the state of ______________

Signature of Practice Owner: ______________________________ Date: _________

FAX SIGNED FORM TO 352-735-0889

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!
"#$%&!#'!()%*+,#%-.!($/)&!01%)2$!34546!7%*-)&*8,!x!9#:8!;4!<*)2=*%!5>4(46!?474!3$%@*,)82!A=)+*8-*&!)8!BCD!!
E%*2#%F!B%$G*%!5>4(46!7:4!(46!?)+*!7%*-)&*8,!A=)+*8-*&!)8!H5D!