SDUS Member Renewal or App Form

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San Diego Urological Society SDUS Logo

Membership Application

and Dues Renewal

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

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

Urologist - $200

Senior Member -$100

APN/PA or Health Professional - $100

Resident/Fellow - $0

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

New Member

Renewal

First Name *

Middle

Last Name *

Title

Organization / Company

Office Address 1 *

Address 2

City *

State/Province/Region *

Zip/Postal Code *

Country *

Email Address: (for confirmation) *

Optional Email Address: (for billing)

Phone *

Fax

Optional: Personal or business web site for directory listing

This section for urologists only - skip if not applicable:

Board Certified?

Yes

Year of Certification:

If no, are you board eligible?

Yes

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

Maybe

Comments:

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

I hereby make application to the San Diego 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.

Questions: Please contact us at 714-550-9155 or via email at dues@desantisgroup.com