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Urologic Society for Transplantation
and Renal Surgery
Membership Application
and Dues Renewal Form
Thank you for supporting the USTRS! The annual dues are payable in US dollars and may be paid by check or credit card on the next page.
Your application or renewal will be acknowledged by email.
New Member or Renewal?
*
New Member
Renewal
Membership Category:
*
Active member- $100
Resident - $0
Fellow - $0
Optional: Pre-pay additional dues/years
Two Years $100+
Three Years $200+
Four Years $300+
Five Years $400+
First Name
*
Middle
Last Name
*
Month and Year you will finish Residency/Fellowship:
Medical School /Program:
Year of Birth:
*
The address below will be used for directory listing and all correspondence.
Facility or Organization
Address 1
*
Address 2
City
*
State/Province/Region
*
Zip/Postal Code
*
Country
*
Email Address:
*
Best Phone
List any social media, e.g. Twitter, LinkedIn or prof. web site for directory listing
Board Certified?
Yes
No
If yes, year eligible:
Medical School & Year completed:
Year of Certification:
State/Country of Licensure:
If no, are you board eligible?
Yes
No
Are you interested in a future leadership role?
Yes
No
Maybe
General Comments:
Zcode
Optional
: Make a tax deductible contribution to the
Dr. John Barry Traveling Fellowship Award in Transplantation.
All Benefactors shall be acknowledged in the meeting program and website. Thank you for helping USTRS.
Donation - $50
Donation - $100
Donation - $200
Donation - $300
By my application, I hereby agree to abide by the Bylaws of the Urologic Society for Transplantation and Renal Surgery.
Click "Continue" button below. On the next page you may pay your fees by check or by credit/debit card using the PayPal checkout cart.