WSAUA Allied Membership Form

Western Section AUA
APP-Allied Membership Application or Dues Renewal

Please complete this 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. *

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

New Member

Renewal

First Name *

Middle

Last Name *

Title

Credential

Organization / Company

Address 1 *

Address 2

City *

State/Province/Region *

Zip/Postal Code *

Country *

Email Address: (for confirmation) *

Phone *

Fax

Optional: Personal or business web site for directory listing

Date of Birth: *

Licensed? *

Yes

No

Year License Issued
or Renewed:

Percentage of
Practice Urology?

Training School & Year Grad:

Years in your
field of work:

Other Medical Organization
Memberships:

Applicants for membership must give the name and city/state of a sponsoring

Active or Senior member of the Western Section who are personally familiar with the applicant.

Please attach your curriculum vitae or resume

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

I certify that to the best of my knowledge, the information which I have provided is true and complete. I hereby authorize the Western Section AUA to verify any data provided with this application. If accepted, I agree to conform to all applicable By-laws and membership requirements of the Western Section AUA.

Signature: (typed name constitutes signature) *

Date: *

Comments:

Acode

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.

Office Management - $75	Advanced Practice Practitioner - $75
Physician Assistant- $75	ANP/NP - $75
Tech/Medical Assistant - $75