WSAUA Membership Application

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Western Section AUA
Membership Application

Active

Associate

Affiliate

Corresponding

Please complete this application and payment. Your initiation fee of $250 (also your first year dues payment) is paid on the next page and will be acknowledged by email.

Application does not confer membership - all information provided is subject to review and approval. Thank you!

Choose category for your application: *

Active Membership

Associate Membership

Affilliate Membership

Corresponding Memberhsip

Free Meeting Bonus Offer: Yes I wish to receive one free meeting registration by paying my 2nd year dues upfront *

Add dues 2nd year, $250

No thanks, $0

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First Name *

Middle

Last Name *

Suffix *

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Note: Our primary communication to you will be via email

Practice Name / Organization / Company

Address 1 *

Address 2

Work City *

State/Province/Region *

Zip/Postal Code *

Country *

Email Address: * 🛈

Secondary Email Address:

Work Phone * 🛈

Preferred Phone (only used as backup) 🛈

Optional: Personal or business web site for directory listing

Optional: Twitter handle (e.g. #urodoc12345 )

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Residence Address:

Address 1 *

Address 2

City *

State/Province/Region *

Zip/Postal Code *

Country *

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My preferred mailing address is: *

Office

Residence

Date of Birth: *

Place of Birth: *

Are you a legal citizen of the
country in which you practice? *

Yes

Gender: *

Male

Female

Spouse Name, if any:

Date and Place of Licensure:

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Applicants for Active membership must be certified by the American Board of Urology, Inc., the Royal College of Surgeons in Canada, the Quebec Board of Urology or the certifying board for urology in the foreign country where the applicant is practicing.

Year of Certification:

Certifying Board:

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Applicants for membership must give names and addresses of two (2) sponsoring Active or Senior members of the Western Section who are personally familiar with the applicant - in accordance with Western Section By-law requirements.

Name *

Email or Address: *

Name *

Email or Address:: *

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Medical School Attended: *

Location: *

Date of Graduation: *

Degree(s): *

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Urological Residency Program: (give name of program and dates)

Program: *

Dates From - To: *

Is the program approved by the Accreditation Council for Graduate Medical Education or the Royal College of Physicians and Surgeons of Canada?: *

Yes

Advanced post-urological training.
Give the names of the institutions, cities and dates of service: *

0/500 words

Where have you practiced since completing your urological residency? Give dates and locations. *

0/500 words

What percentage of your practice is urological? *

Hospital appointments now held. Give size, type of hospital and location. *

0/500 words

Teaching positions held, past or present.
Give title of position such as Assistant or Associate Professor, Chief, etc. *

0/500 words

Disciplinary Actions (if you answer yes to any of the statements below, please provide an explanation with your application.)

Has your professional license ever been suspended, terminated, limited in any way or reduced in scope? *

Yes

Have you ever had hospital staff privileges denied, reduced in scope or rescinded for cause? *

Yes

Have you ever had disciplinary action taken against you at any time by a professional society, academic institution or government agency? *

Yes

Explanation:

0/300 words

FILE ATTACHMENTS - For convenience, you may upload documents here or mail / email them to us later.

Please submit your curriculum vitae with this application.

Please submit a "head and shoulders" style photo of yourself, any size.

Please submit evidence of graduation from a medical school.

Please submit evidence of certification by the American Board of Urology, the Fellowship in Urology by the Royal College of Surgeons of Canada (Certificate copy, or letter), or other certifying board.

Optional Comments:

0/100 words

I certify that to the best of my knowledge, the information which I have provided is true and complete. I hereby authorize the Western Section AUA to verify any data provided with this application. If elected, I agree to conform to all applicable By-laws and membership requirements of the Western Section AUA.

Signature: (typed name here constitutes your signature) *

Date: *

I certify that I have read and understand the bylaws . *

Yes

I give permission to WSAUA to use and release this information to obtain confidential letters of recommendation on my behalf from the sponsors I have named herein. *

Yes

Click "Continue" button below. On the next page you may pay your initiation fees/dues by credit card or by check. A confirmation email will be sent to you with a copy of this application.

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 tax purposes.

Questions: Please contact us at 714-550-9155 or via email at info@wsaua.org