AHIP Full Membership 2024

Name: AHIP Full Membership 2024
SKU: ahip-membership-2024
Availability: InStock

AHIP Memberships run from January 1st – December 31st and are prorated based on the month you join.

2024 Graduates only, to apply for Full membership, but DO NOT HAVE YOUR DIPLOMA, please download and use the manual Full Membership application.

A. APPLICANT INFORMATION

Last Name *

Please provide a valid last name.

First Name *

Please provide a valid first name.

Middle Name

Please provide a valid middle name.

Name as you wish it to appear on your certificate *

Please provide a valid name as you wish it to appear on your certificate.

Home Street Address *

Please provide a valid home street address.

Apartment, Suite, Unit, etc

Please provide a valid apartment, suite, unit, etc.

Town / City *

Please provide a valid town / city.

Province *

Please provide a valid province.

Postal Code *

Please provide a valid postal code.

Home or Cell Phone *

Please provide a valid home or cell phone.

Work Phone *

Please provide a valid work phone.

Date of Birth (DD/MM/YYYY) *

Please choose a valid date of birth (dd/mm/yyyy).

Employment full & complete name, address, city (incl. Postal code) *

Please provide a valid employment full & complete name, address, city (incl. postal code).

Member contact personal email address***(mandatory)*** (not work email) *

Please provide a valid member contact personal email address***(mandatory)*** (not work email).

Are you or your employer currently an assistive devices program vendor? *

Yes

Please choose a valid are you or your employer currently an assistive devices program vendor?.

B. EDUCATION

Please indicate any college or university education aquired or attending at present.

Name Of Institute *

Please provide a valid name of institute.

Province (Location) *

Please provide a valid province (location).

Years Completed *

Please provide a valid years completed.

Degree *

Please provide a valid degree.

Major Subjects *

Please provide a valid major subjects.

Completion Date *

Please provide a valid completion date.

C. EMPLOYMENT

Begin with your present place of employment. List every position held for the past 5 years.

Name & Complete Address of Employer *

Please provide a valid name & complete address of employer.

Dates of Employment *

Please provide a valid dates of employment.

Duties *

Please provide a valid duties.

Full / Part Time *

Please provide a valid full / part time.

Name & Title of Supervisor *

Please provide a valid name & title of supervisor.

Reason for Leaving *

Please provide a valid reason for leaving.

D. QUALIFICATIONS

Length of experience actively and principally engaged in the practice of the testing of hearing and the selection, and or fitting and dispensing of hearing instruments.

Years *

Please provide a valid years.

Months *

Please provide a valid months.

E. REFERENCES

Business References

Company *

Please provide a valid company.

Address *

Please provide a valid address.

Phone

Please provide a valid phone.

Company *

Please provide a valid company.

Address *

Please provide a valid address.

Phone

Please provide a valid phone.

Professional References

Company *

Please provide a valid company.

Address *

Please provide a valid address.

Phone

Please provide a valid phone.

ATTACH DOCUMENTS

This application must be accompanied by a valid Certificate of Insurance for Professional Liability for a minimum of $2,000,000.
First time members must also provide a proof of graduation (diploma) when applying for membership.

Certificate of Insurance *

Please choose a valid certificate of insurance.

(Must be valid in current year)

College Diploma *

Please choose a valid college diploma.

(College Program Transcripts or Program Completion Letters are Not Accepted)

APPLICANT’S AFFIDAVIT

I hereby make application for membership in the Association of Hearing Instrument Practitioners of Ontario, and if accepted, I will abide by the By-Laws, Policies and Code of Ethics as established by the Association. I understand that failure to do this may be cause for cancellation and recall of my Certificate and expulsion from the Association. I further understand that continuance of my Membership is conditional upon my meeting the requirements for annual renewal of my Certificate.

I acknowledge that the Certificate of Membership is the property of the Association and that it will be returned upon demand by the Association.

Signature *

This signature is required.

Clear

Date *

Please choose a valid date.

PROCESSING YOUR APPLICATION MAY TAKE UP TO 2-3 WEEKS. WHEN YOUR APPLICATION IS APPROVED, YOU WILL RECEIVE OFFICIAL NOTIFICATION BY MAIL FROM AHIP.

AHIP WILL NOT CONSIDER ANY APPLICATIONS THAT ARE NOT COMPLETE.

First payment: April 1, 2025

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