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Tinnitus Care Provider Certificate Program

November 8-9, 2019
Marriott Chicago O’Hare Airport
Chicago, Illinois



Please complete all fields.
Membership: IHS Member
I am not an IHS member but would like to join
Prefix: * Mr. Mrs. Ms. Dr.
First Name: *
Middle Initial:
Last Name: *
Credentials (ACA, BC-HIS, PhD, etc.):
Job Title: *
(Choose all that apply)

Owner/President/CEO
Hearing Aid Specialist
Audiologist
Spouse/Guest
Trainee
Account/Sales Representative
Marketing
Operations
Other
Company: *
Street Address: *
Street Address (2):
Mail Stop/P.O. Box:
City: *
State/Province: *
Zip/Postal Code: *
Country: *
Phone: *
Format: (---)---.----
Fax:
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Cell:
Format: (---)---.----
E-mail: *
Company Website:
Birth Date:
Format: MM/DD/YYYY
License Number
License State/Province
Date the license was issued
Last 4 digits of Social Number
Gender Male Female
Tell us about yourself *
Owner/President/CEO
Employee
Retired
Select your profession *
Hearing Aid Specialist
Audiologist
Trainee/Student
Audiology Assistant
Office Staff
ENT
Medical Doctor
Professor/Educator
Other
What year did you start dispensing hearing instruments? *
Which of the following best describes your work environment? *
Private Practice/Clinic
Retail (ie. Costco)
Franchise
Manufacturer-owned Retail
Educational Institution
Manufacturer
Hospital/Medical Clinic
N/A
Other
Do you fit devices from more than one manufacturer? * Yes No
What is the highest academic degree you have earned? *
High School Diploma or GED
Some College
Associate's degree in Applied Science
Associate's degree in Arts
Associate's degree in Science
Bachelor's degree
MBA
Master's degree in Arts
Master's degree in Science
PhD
AuDbn
Other
What are your reasons for attending this program? *

How did you hear about the Tinnitus Care Provider Certificate Program? *

Dietary Restrictions
Please note that in order for you to make food choices appropriate to your dietary needs; we have requested the hotel to label food items. This includes noting on food labels if an item is dairy free, vegetarian, or gluten free. If you have religious or dietary restrictions indicate below.

Registration Fees
Fees * On or before August 31 On or after September 1
IHS Member Price $1,695 USD $1,795 USD
IHS Non-Member Price $2,225 USD $2,325 USD
Join IHS & Register – Save $ Now! $2,020 USD $2,120 USD

* An additional assessment fee of $300 USD is paid at the time the candidate makes the examination appointment.

Coupon Code (if applicable)

Payment Method:
Choose your method of payment Visa MasterCard American Express Discover
Name on Card *
Card Number *
Expiration Date *
Security Code *

Registration Policies
  • The registration fee includes the two-day workshop, the participant guide, pre-workshop assignments, Dr. Tyler’s book (Tinnitus Treatment: Clinical Protocols), four meals, one reception, and a certificate of completion. The assessment fee is paid separately when making the examination appointment. The assessment must be taken within 30 days after the workshop.

  • Cancellation and Refund Policy:
    To be valid, IHS must receive notification of your cancellation in writing. A refund minus a $50 processing fee will granted for cancellation requests received on before October 1, 2019, A refund minus a $100 processing fee will be granted for cancellation requests received between October 2, 2019 and October 31, 2019. Beginning November 1, 2019, no refunds will be given. However, a substitute may attend.

  • Special Accommodations: If you require a special accommodations to fully participate, please contact IHS at 734.522.7200.



Upon successful completion of the program, I agree that IHS may list my name publicly in a directory on an IHS webpage and through various IHS publications congratulating new certificate holders.
Yes No *




IHS
16800 Middlebelt Road, Suite 4
Livonia, MI 48154
(734)522-7200


More Info
General Information
How the Program Works
Registration
Fees
Assessment
Mission Statement
Vision Statement
Curriculum
Accreditation & Continuing Education
About Certificate Programs
Workshop Agenda
Hotel & Transportation
Workshop Location Requests
Assessment Locations
Candidate Registry
Additional Resources