American Conference of Audioprosthology

American Conference of Audioprosthology 16880 Middlebelt Road, Suite 4 Livonia, MI 48154 P 734.522.7200 F 734.522.0200

I am interested in enrolling in the Audioprosthology educational program. Please contact me when a class is available in my area.

Address

Phone ______Fax ______

Level of Education  High School  College Degree

 Some College  Post Graduate Degree

Years of Field Experience ______(2-year minimum required)

Licensed to dispense hearing aids  Yes  No

I am licensed in the following states: ______

______

Board Certified by NBC-HIS  Yes  No

Date Submitted ______

I understand that a $50 registration fee is required and the complete cost of the program is $3,050, payable in monthly installments.