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