iCAN Membership Application for Practice Owners

Are you an Independent Audiologist, able to offer patients a choice of manufacturers' products and not bound to any specific brand? *

Yes I am independent
No I am not currently independent

If you answered "No" above, please indicate what avenue of audiology you currently work in *

Retail
Industrial
Rep
Other

Name *

First

Last

Title

Email *

Mobile number *

Date of birth

HPCSA number *

BHF number *

Province *

Practice Name *

Practice Address *

Practice phone number *

Practice email address *

If your practice is VAT registered, please enter your VAT number belowing for invoicing purposes

Do you have a second branch? *

Yes
No

Second practice address (incl phone number and email address if different from main branch)

Do you have a third branch? *

Yes
No

Third practice address (incl phone number and email address if different from main branch)

Do you have a fourth branch? *

Yes
No

Fourth practice address (incl phone number and email address if different from main branch)

Do you have a fifth branch? *

Yes
No

Fifth practice address (incl phone number and email address if different from main branch)

Do you have partners in your practice who may join iCAN? If so, please list their names here

Practice website / URL

Social platforms (enter the LINK to your Facebook, Instagram, LinkedIn, etc accounts; as in https://xxxxx.com/abchearing)

Practice Details

Please tick all relevant information regarding services and equipment to help facilitate the development of our database for collegial referrals.

Services offered: *

Equipment at your practice

Any other equipment?

Affiliations *

Malpractice Insurance by AON is offered at a discounted rate to iCAN members. Should you opt-in for this, you will be invoiced for the annual premium amount. *

Yes - I would like AON cover and will pay the discounted premium
No - I do not require cover

By ticking the box below I acknowledge that my acceptance of the iCAN Code of Conduct and this serves as my legally binding signature acknowledging that I have thoroughly reviewed, understand and accept the iCAN Code of Conduct. The document can be viewed and downloaded here

iCAN Code of Conduct *

I accept

PLEASE READ FIRST

The iCAN Membership Agreement requires you to insert your name on page 1, your physical and email address on page 9 and your signature in the correct MEMBER space on page 16. Check this box below to confirm that you have read this agreement which can be downloaded HERE. Once completed and signed, you must upload the FULL, completed agreement using the space below.

iCAN Membership Agreement *

I accept

Upload your signed Membership Agreement here (.pdf only) *

Click or drag a file to this area to upload.

When clicking "Continue", you will be directed to create your logins for the member-only content and then to PayFast to set up your monthly subscription. If you do not complete ALL these steps, the application can not be processed.