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WSAUAWestern Section AUA
Membership Application


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: *
Free Meeting Bonus Offer: Yes I wish to receive one free meeting registration by paying my 2nd year dues upfront *
Note: Our primary communication to you will be via email
Residence Address:
My preferred mailing address is: *
Are you a legal citizen of the
country in which you practice? *
Gender: *
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.
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.
Urological Residency Program: (give name of program and dates) 
Is the program approved by the Accreditation Council for Graduate Medical Education or the Royal College of Physicians and Surgeons of Canada?: *
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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? *
Have you ever had hospital staff privileges denied, reduced in scope or rescinded for cause? *
Have you ever had disciplinary action taken against you at any time by a professional society, academic institution or government agency? *
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FILE ATTACHMENTS - For convenience, you may upload documents here or mail / email them to us later.

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

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