Mail this registration form and payment to:
Joe Rosengarten, Treasurer, Hearing Healthcare Alliance of Ohio, 6601 Taywood Drive, Englewood, OH 45322-3761

Please Print Legibly!

Name:

Address:

 ________________________________________

City/State/Zipcode:

 ________________________________________

Phone:

 ________________

Amount Enclosed: $___________

Check Number:* _____________
* There is a $30.00 returned check charge