WSAUAWestern Section AUA
Active / Associate / Affiliate / Corresponding
Membership Application
Please complete this application and click the submit button on the second page. Your initiation fee of $250 (also your first year dues payment) will be acknowledged by email. Information provided is subject to review by the Membership Committee and AUA. THANK YOU!

I, the undersigned, herewith apply for: *
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Office Address:  
Notice: By giving us your phone, fax and email address, you give the WSAUA and AUA permission to use it.
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Residence Address:
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My preferred mailing address is: *
Are you a legal citizen of the
country in which you practice? *
Gender: *
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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.
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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.
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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?: *
0/500 words
0/500 words
0/500 words
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Disciplinary/Legal Actions (if you answer yes to any of the statements below, please provide an explanation with your application. Failure to respond or inaccurate responses may be grounds for non-acceptance or expulsion from membership.)
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Have you ever had hospital staff privileges denied, reduced in scope or rescinded for cause?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? *
Have you ever been convicted of or pleaded guilty to a felony or other serious crime? *
0/300 words

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




0/100 words
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 of $250 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