NAME: _________________________________________ADDRESS: _________________________________________

TELEPHONE: _________________________ (TTY: ___YES, ____NO) E-MAIL ADDRESS: _________________________________________ANNUAL ACTIVITY FEE (per Calendar year): SINGLE $15/YR _____ FAMILY $25/YR _____SPOUSE (if family participation): _________________________________DO YOU REQUIRE ANY ASSISTIVE LISTENING DEVICES FOR MEETINGS? YES___ NO___ IF YES, PLEASE SPECIFY:________________________________________________________________BRIEF HISTORY OF HEARING DIFFICULTY:__________________________________________________________________________________________________________________________________________________________________________ARE YOU INTERESTED IN SERVING ON ANY CHAPTER COMMITTEES, SUCH AS MEMBERSHIP, PUBLICITY, NEWSLETTER, OUT REACH, FUND RAISING?

YES ____ NO ____. IF SO, PLEASE SPECIFY AREA OF INTEREST: ________________________________________________________________ARE YOU A MEMBER OF THE NATIONAL ORGANIZATION, Hearing Loss Association of America, INC.? YES_____ NO _____