AZUS Membership Form

Arizona Urological Society

Dues Renewal
Membership Application

Please complete this simple form and the payment on the next page.
Your application or renewal will be acknowledged by email. THANK YOU!

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

New Member

Renewal

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

Active Urologist - $200

Urologist Senior Member - $100

Affiliate Member (APP/NP/RN/PA) - $0

Resident/Fellow Member - $0

Corresponding Member (out of state) - $100

First Name *

Middle

Last Name *

Title

Organization / Company

Office Address 1 *

Address 2

City *

State *

Zip/Postal Code *

Country *

Email Address: (for confirmation) *

Phone *

Fax

Optional: Personal or business web site for directory listing

This section for new member 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:

Are you interested in a leadership role?

Yes

No

Maybe

Comments:

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

I hereby make application to the Arizona Urological Society and I agree to abide by the Articles of Incorporation and 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.