Membership Application – HAC Task Force

Membership Application
Contact

Membership Application Contact

Membership Application

November 15, 2019

Organization *

Primary Contact *

First

Last

Title

Phone *

Email *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Is the primary contact also the billing contact? *

Yes
No

Billing Contact *

First

Last

Title

Phone *

Email *

Please select the option below that best describes the entity applying to join the HAC Task Force. *

Wireless OEM ($53,000)
Wireless Service Provider - Tier 1 ($53,000)
Wireless Service Provider - Tier 2 ($15,000)
Wireless Service Provider - Tier 3 ($5,000)
Hearing Aid Manufacturers and Representative Associations ($7,500)
Research and Academic Institutions ($0)
Other ($2,500)

If you answered "Other" to the previous question, please elaborate.

HAC Task Force Operating Procedures *

Applicant agrees that, upon approval of participation in the HAC Task Force, it will abide by the Task Force Operating Procedures.

Name

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