AuDConnex Canada | New Member Form

Member App Log In

1-888-571-5107

1-888-571-5107

Member App Log In

Why AuDConnex?
Benefits
Partners
Management/Resources
Learn About AuDConnex
Join AuDConnex

New Member Sign-Up Form

1 Practice Name

2 Contact Details

3 Partnership Information

Practice Information
Name of Practice*
Name
First Last

Contact Information
Birthdate (optional)
Address
Street Address Address Line 2 City Province Postal Code
Phone
Extension
Please enter a value between 1 and 999999.
Email*
Enter Email Confirm Email

Partnership Information
Referral Source*
Please note:

If you have an account number with Starkey, you don't need a new account number. You can use your existing account number. If you don't have an account number and want one, please indicate. Thank you.
Starkey*
- Existing account holder. (Enter your account number below.)
- Need an account.
- Not interested.
Starkey Account #
Siemens*
- Existing account holder. (Enter your account number below.)
- Need an account.
- Not interested.
Siemens Account #
Widex*
- Existing account holder. (Enter your account number below.)
- Need an account.
- Not interested.
Widex Account #
OakTree Products*
- Existing account holder. (Enter your account number below.)
- Need an account.
- Not interested.
OakTree Account #
Blueprint Solutions*
- Existing account holder. (Enter your account number below.)
- Need an account.
- Not interested.
Blueprint Account #
Simply Hearing Solutions*
- Existing account holder. (Enter your account number below.)
- Need an account.
- Not interested.
Simply Hearing Account #
Etymotic Research*
- Existing account holder. (Enter your account number below.)
- Need an account.
- Not interested.
Etymotic Research Account #
Grand & Toy*
- Existing account holder. (Enter your account number below.)
- Need an account.
- Not interested.
Grand & Toy Account #
The Lewis Agency*
- Need an account.
- Not interested.