Provider Database Registration

Welcome to the Provider Network.
If you are new to the Provider Network and you would like to become a member, choose a username and password and fill out the information below to get started.

Provider Information*

Username:	(3-20 characters)
Password:	(3-20 characters)
Re-type Password:
Provider Name:
Facility or Business Name:
Business Type:
Business Address:
City:
State:
Zip:
Country:
Contact Person:
Phone:
Fax:
Email:

*All fields, except fax, are required.

Additional Database Information

Provider Affiliations

E.A.R., Inc./Insta-Mold

FreeHearingTest.com

Special Identity Logos

	ADA		AFA		Au.D.		Ph.D.		M.D.
	H.I.S.		M.S.		M.A.		CCC-A		F-AAA

Markets Covered
Check each market you are involved in.

Auto Racing	Aviation	Children/Pediatrics	Dentistry/Medical
Hearing Aids	Industrial	Law Enforcement	Meditation/Sleeping
Motorcycling	Music	Shooting	Swimming

Products Covered
Check each product which you market or carry.

Electronic Earplugs	Non-Electronic Earplugs	Filtered Earplugs	Foam Earplugs
Ear Muffs	Temporary/Reusable Earplugs	Specialty Earmolds	Water Protection
Specialty Products	Hearing Maintenance	Hearing Aid Batteries	Health Supplements

Professional Services
Identify all services your facilty is equipped to do.

ABR-Diagnostic	ABR-Screening	Assistive Listen Devices	Audiometric Evaluations
Balance/Dizziness	Battery Club	Cochlear Implants	Comprehensive Hearing Test
Custom-Fit Hearing Aids	Earwax Removal	Hearing Aid Repair/Service	Hearing Aid Sales/Service
Hearing Screening/Evaluation	Industrial Testing	Middle Ear Implants	Multi-Line Hearing Aids
Pediatric Testing	Sign Language	Specialty Earmolds/Protection	Tinnitus Therapy
Video Otoscopy

Website Development/Linking

	Yes, I have a website I would like to link to my listing.
	Please contact me for further details on designing my own website through ICSWebmaster.com
	I don't have a website and I'm not interested in one at this time.

Listing Options

	Yes, I am an E.A.R., Inc. provider and would like to be listed in the database for free.
	No, I am not an E.A.R., Inc. provider but would like more information on how to join to obtain a free listing within the database.
	No, I am not an E.A.R., Inc. provider and do not wish to join for a free listing within the database. We will be choosing from the following payment plans.

Additional Comments
If you have any special instructions, please explain in the space provided: