!"#$#""#%&!"'()%#"&*'++,-).

/&
01',.&&
!"#$%&'()*%+%**%,)*-./,%*0-11"2/&34))05/(61%17%*(8/9Ͳ,*/.%2:-11"2/&3&86&-++%*(;<=<
76(%,6",/->-?/(&(6(&*%61>/2%,@63&-*%6:8:-2("1%*(/2(%6*:8-+!"#$#%!8%6*/2?:6*%<A8*-"?8
!"#$%&'(:-2("1%*Ͳ+6:/2?@%7(/&%B@@@<$-@/C%6*<:-1B6",/->-?/(&(:629*-1-&%&8%/*:>/2/:(62,
9*6:&/:%("(/2?&8%:-19623'(!"#$%&%'$()*%+,)%-./+01%&%'2< 

!"#$%&'(">&/16&%?-6>/(&-%,":6&%:-2("1%*(67-"&6",/->-?3:6*%B62,,*/.%&8%1&-
$-@/C%6*<:-1@8%*%&8%3:62+/2,626",/->-?/(&/2&8%/*>-:6>6*%6&-?%&&8%:6*%&8%3&*">32%%,62,
,%(%*.%<
!

2#-#$).3&&
D2:%3-"86.%9"*:86(%,&8%3%6*>3))01%17%*(8/9B3-"*:>/2/:-*9*6:&/:%/(6"&-16&/:6>>36,,%,&-
!"#$%&'(!"#$%&%'$()*%+,)%-3$-/+)%-2-2$-@/C%6*<:-1<A8%))0-++%*((%.%*6>7%2%+/&(&-/&(
1%17%*(/2:>",/2?E 

o !"2/F"%-99-*&"2/&3&-("99-*&!"#$%&'(:-2("1%*%,":6&/-2,/./(/-2@8/:8(%%G(
&-%,":6&%&%21/>>/-2!1%*/:62(67-"&6",/->-?3:6*%62,9*-./,%HIBIIIfree
hearing protection devices&-:-2("1%*(73JIHH<
o K%6,?%2%*6&/-2&8*-"?8$-@/C%6*<:-1L--?>%M!,N-*,O:6196/?2(<
o K%6,?%2%*6&/-2&8*-"?826&/-26>1%,/69"7>/:*%>6&/-2(-"&*%6:8<
o C/?8>/?8&%,62,&-9>%.%>9>6:%1%2&-2&8%!",/->-?/(&K-:6&-*#/*%:&-*3<
o !",/->-?3M7*62,6@6*%2%((O&8*-"?8?*6((*--&(16*G%&/2?62,9*-1-&/-26>
%++-*&(<
o !::%((&-7%&&%*9*/:%,8%6*/2?6/,(&8*-"?8&8%7"3/2?,/./(/-2<
o !::%((&--2?-/2?6",/->-?37"(/2%((62,%,":6&/-2*%(-"*:%(62,("99-*&< 

&'()*)+'),-452%"(/&&!"#0/,-$1',$#)0-%"'0,667-/5/--,&%1
8%9$:/,-;+%<=2%"9$&&<%-/)0,1)-$>&/2%"-%-$'$1,&$1?/()</1);4)@()0,)+%()Ͳ
/55/+)$?/=,1#)0,)($<>&/A
!

45'&67-&8')-9&
!",/->-?/(&(>/:%2(%,/2&8%;2/&%,=&6&%(<

!"#$%&'()*+,(x(-...(/01&(-23&4(5&6%%&(x(5"7&%(-8-(x(9"6*1:7;;%'!<7**%1=&0((>>??@(
!
"#$%&!#'!()%*+,#%-.!($/)&!01%)2$!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!

!"#$#""#%&!"'()%#"&*'++,-)./&
:';&%'&<&8')-9&
P-/2/2?&8%)*%+%**%,)*-./,%*0-11"2/&3/(%6(3Q=/19>3+/>>-"&&8%+-*17%>-@B("71/&9631%2&
/2+-*16&/-2B62,@%'>>,-&8%*%(&<
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

!"#$%&'()*+,(x(-...(/01&(-23&4(5&6%%&(x(5"7&%(-8-(x(9"6*1:7;;%'!<7**%1=&0((>>??@(
!
"#$%&!#'!()%*+,#%-.!($/)&!01%)2$!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!

Sign up to vote on this title
UsefulNot useful