<p> American Conference of Audioprosthology 16880 Middlebelt Road, Suite 4 Livonia, MI 48154 P 734.522.7200 F 734.522.0200</p><p>I am interested in enrolling in the Audioprosthology educational program. Please contact me when a class is available in my area.</p><p>Name</p><p>Address</p><p>Phone ______Fax ______</p><p>Email</p><p>Level of Education  High School  College Degree</p><p> Some College  Post Graduate Degree</p><p>Years of Field Experience ______(2-year minimum required)</p><p>Licensed to dispense hearing aids  Yes  No</p><p>I am licensed in the following states: ______</p><p>______</p><p>Board Certified by NBC-HIS  Yes  No</p><p>Date Submitted ______</p><p>I understand that a $50 registration fee is required and the complete cost of the program is $3,050, payable in monthly installments.</p>