Application for EarScan3 Portable Audiometer If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Describe the location (e.g., country/city) and how the EarScan3 Audiometer will be used to improve hearing health services in low resource environments (250 word limit). * Organization/individual requesting the audiometer: Name of organization/individual: * Shipping Address Line 1 * Shipping Address Line 2 City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code * Email * Phone * Website (if applicable) Review of applications: A committee of experts appointed by the CGHH Board will judge the likelihood that the proposed use of the audiometer will contribute to improved hearing health in the setting for which it is requested. Each application will be approved or disapproved within 90 days of submission.
