SGSU Membership Form

Society of Government Service Urologists
Membership Application
and Dues Renewal

We welcome you! Please select one choice below. The annual dues amount may be paid by check or credit card on the next page. Your application or renewal will be acknowledged by email. THANK YOU!

USAV Members: Select VA/USAV category

New Member or Renewal? *

New Member

Renewal

Please select category: *

Optional: Pre-pay additional dues/years

Two Years $100+

Three Years $150+ (save 50)

Four Years $225+ (save 75)

Five Years $300+ (save 100)

Optional: Pre-pay additional dues/years

Two Years $150+

Three Years $250+ (save 50)

Four Years $350+ (save 100)

Five Years $450+ (save 150)

Please complete if active or retired military or change in status or rank.

First Name *

Middle

Last Name *

Gender

Male

Female

Date of Birth: *

Service *

Years of Service:

Military Status

Military Rank/Title

Organization / Institution / Company

Address 1 *

Address 2

City *

State/Province/Region *

Zip/Postal Code *

Country *

Email Address: (for confirmation) *

Phone *

Fax

List any social media, e.g. Twitter, LinkedIn or prof. web site for directory listing

Home or Alternate Address

Address 1

Address 2

City

State/Province/Region

Zip/Postal Code

Country

Phone

Email Address:

This section for Residents only - skip if not applicable:

Month and Year you will finish Residency:

Medical School /Program:

This section for 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 completed:

Optional: Support the SGSU!
All Benefactors shall be acknowledged in the meeting program and website.
Thank you for helping SGSU!

Are you interested in a future leadership role?

Yes

No

Maybe

If yes or maybe, is there a specific area of interest to you?

General Comments:

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

By submitting my application, I hereby agree to abide by the Bylaws of the Society of Government Service Urologists and if applicable, the USAV.

Receive an email copy of this renewal

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 a professional or business expenses to the extent allowable by law. Dues and other contributions to SGSU are not deductible as charitable contributions for federal income tax purposes.

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