CENTRAL STATES CONFERENCE ON HEARING
2009 Annual Convention & Education Seminar

Branson Convention Center Hotel
Branson, MO
March 12-14, 2009

ADVANCED REGISTRATION FORM
You may print this form for your convenience.

Name  _______________________________________________________________
Company  _______________________________________________________________
Address  _______________________________________________________________
City State Zip  _______________________________________________________________
Telephone/ Email  (____)_______________________ (____)_____________________________
E-Mail  _______________________________________________________________

Please check:

q Audiologist   (q ASHA  q  AAA)                 
q Hearing Instrument Specialist
q Other (________________________________)

Conference Fees: 

Conference

 

After 02/14/09

OHAA Members* q $235.00 q $285.00
Non-Members q $335.00 q $385.00
Thursday Only Member Fee q $75.00 q $100.00
Thursday Only Non-Member Fee q $125.00 q $150.00
Friday Only Member Fee q $150.00 q $175.00
Friday Only Non-Member Fee q $200.00 q $225.00
Saturday Morning Only Member Fee q $75.00 q $100.00
Saturday Morning Only Non-Member Fee q $125.00 q $150.00
Saturday Afternoon (Westone    
Spouse Package (meals/exhibits hall only) q $100.00  
Spouse Name _________________________    
Paying by credit card:    q Visa     or  q Mastercard

Charge Card No. ____________________________________

Name of Card Holder _________________________________

Expiration Date:_______/_________

TOTAL Enclosed


$_____________


PLEASE CHECK STATE(S) WHERE CEU’S ARE NEEDED:
State's CEU’S Needed
 

Arkansas
Illinois
 
Iowa
 
Kansas
 
Missouri
 
Nebraska
 
Oklahoma
 
*Texas
 

Hearing Aid Dispenser
CEU’S

q
q
q
q
q

q
q
q

Audiology
CEU’S

q
q
q
q
q

q
q
q

*An additional fee will be charged for Texas registrants requiring CEU’s
 

Make check payable and return with the registration form to:

CENTRAL STATES CONFERENCE ON HEARING
c/o Missouri Hearing Society
P.O. Box 1072
Jefferson City, MO 65102
or
c/o Oklahoma Hearing Aid Association
2323 South Sheridan
Tulsa, OK 74129
Must register prior to February 14
th to avoid additional fees.

horizontal rule

REFUNDS: Full refund of fee will be made if cancellation notice is received at least two weeks prior to the opening date of the convention. (Must be postmarked by February 26th or before). A 50% refund will be made if cancellation is received by 5:00 p.m. March 3, 2009. NO REFUNDS WILL BE MADE AFTER MARCH 4, 2009.