USAV Membership Form

USAV Membership Application
and
Dues Renewal

Please complete items below. The annual dues may be paid by check or credit card on the next page. Your application or renewal will be acknowledged by email. Thank you!

Application for: *

New Member

Renewal

USAV & SGSU (dual):

Active, Urology MD/DO ($125)	Allied Urology ($110)
Resident-Fellow-Med Student ($20)

First Name *

Middle

Last Name *

Gender *

VA Facility or Organization

Mailing Address *

Address Line 2

City *

State *

Zip Code *

Email Address: *

Non-VA Email Address:

Office Phone *

Cell Phone

Medical School

Year

Residency Program

Year

Fellowship Program

Year

Board Certification

Year

Allied (PA/NP/RN)

Year

Add Wall Certificate of USAV membership ($30 inclusive of shipping & handling)

Wall Certificate, $30

Name & degree on certificate:

I would like to make a donation to support USAV:

$25 Donation

$50 Donation

$100 Donation

Other Support Amount:

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

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 USAV/SGSU are not deductible as charitable contributions for federal income tax purposes.