CUA Dues & Membership Form

California Urological Association
Membership Application
or Dues Renewal

Thank you for your supporting the CUA. Please complete this simple form and the payment page. Your application or renewal will be acknowledged by email.

New Member or Renewal? If renewal, you only need complete the required fields. *

New Member

Renewal

Please select one choice below. The annual dues amount may be paid by check or credit card on the next page. *

Urologist - $150	Urologist - pay dues for multiple members
Health Pro/Nurse/PA - $100	Resident - $0

You have chosen to pay dues for more than one member - please select one choice below. The annual dues amount may be paid by check or credit card on the next page.

Dues for 2 members - $300	Dues for 3 members - $450
Dues for 4 members - $600	Dues for 5 members - $750

Please list full name and email of Members for whom dues are being paid:

First Name *

Middle

Last Name *

Title

Organization / Company

Address 1 *

Address 2

City *

State/Province/Region *

Zip/Postal Code *

Country *

Email Address: (for confirmation) *

Phone *

Fax

Optional: Personal or business web site for directory listing

This section for urologists only - skip if not applicable:

Board Certified?

Yes

No

Year of Certification:

If no, are you board eligible?

Yes

No

If yes, year eligible:

Medical School & Year:

Percentage of
Practice Urology?

Date of Birth:

Other Urological Organization
Memberships:

California Medical Association member?

Yes

No

Unsure

The CUA Keyman Contact and Rapid Response Network helps us to respond effectively to threats and address critical issues. We are looking for those in leadership positions in other organizations and/or those that may have expertise and/or experience working with public officials. Please let us know and describe any such roles. You will be contacted by CUA for follow-up. Thank you!

Are you interested in a leadership role?

Yes

No

Maybe

If yes, is there a specific area of interest to you?

Comments:

If referred by a colleague, please
let us know who:

Discount Code

I hereby make application to the California Urological Association for Active or Associate Membership and I agree to abide by the Bylaws.

Signature: (typed name constitutes signature) *

Date: *

Click "Continue" button below. On the next page you may pay your fees by credit card or by check.

NOTE: Organization dues may be deductible as professional or business expenses, to the extent allowable by law. Dues and other contributions are not deductible as charitable contributions for federal income purposes.