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Discount Hearing Program Application
Full Name
Job Title/Position
Email Address
Your Phone Number
Organization Name
Business Website URL
Business Address (Street, City, State, ZIP)
How many constituents does your organization have? (Members/employees/residents)
Why are you interested in offering this hearing aid discount program?
Improve employee/member health & wellness
Reduce healthcare costs for hearing-related issues
Offer a valuable benefit to members/employees
Other
How would you plan to inform your members about this program?
Email newsletters
Internal website/intranet
Printed materials/flyers
HR/Member Benefits Office
Company/Union meetings
Social Media
Would you like marketing materials for your members? (Extra cost may apply)
Yes
No
Maybe
Do you have the authority to enroll your organization in this program?
Yes
No
How did you hear about our hearing aid discount program?
Referral
Email Campaign
Social Media
Online Search
Conference/Event
Other
Do you agree to receive program updates and communications from us?
Yes
No
Upload Files
Additional Notes
Submit Application
