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Please select the category that best describes your status:* Select One Fellow Full-Time Administrator Industry Employee Nonphysician Provider Other Other Medical Professional Physician Researcher Resident Student/Trainee Urologist Urology Fellow Urology Resident Fellowship/Residency Program:* Expected Graduation Year:* Select One 2017 2018 2019 2020 2021 2022 2023 2024 2025 Please Check ALL Areas of Practice Emphasis:* (Check all that apply) AndrologyIncontinence - MaleOncologic Urology - All formsBenign Prostatic DiseaseLaparoscopyPediatric UrologyCalculus DiseaseNeurourologyReconstructive UrologyCryosurgeryOncologic Urology - BladderRenal TransplantationEndourologyOncologic Urology - KidneyRoboticsFemale UrologyOncologic Urology - ProstateSexual Medicine - FemaleFetal UrologyOncologic Urology - PenileSexual Medicine - MaleGeriatric UrologyOncologic Urology - RenalDoes Not ApplyIncontinence - FemaleOncologic Urology - Testicular Are you a member of the American College of Surgeons?:* YesNo If "Yes," please enter your member ID to expedite your CME processing: How did you learn about this conference? (Check all that apply) Advertisement in Professional JournalMember NewsletterWebsiteCalendar/Monthly ListingRegistration Brochure MailerWord of Mouth/ColleagueEmail Registrant Information First Name:* Last Name:* Degree(s): Badge First Name:* Address 1:* Address 2: City:* State:* ZIP Code:* Country:* Phone:* FAX: Email:* Address Type:* HomeOffice Meeting Registration Registration Categories* Early Discounted through 1/31/2018 Regular Fees after 1/31/2018 Physician Members $100 $125 Physician Nonmembers $175 $225 Practice Managers - Members $50 $75 Practice Managers - Nonmembers $100 $125 Mid-Level Providers Complimentary Complimentary Residents Complimentary Complimentary Fellows Complimentary Complimentary Students Complimentary Complimentary Industry Employee - Supporting/MSL Industry Employee whose company is already supporting IUA OR Industry Medical Science Liaison (Proof of MSL Title may be required before confirmation of registration) $175 Industry Employee - Non-Supporting Industry Employee whose company is NOT already supporting IUA $875 Your submission will need to be approved prior to confirmation of your registration. Approval may be based on current Industry support. To find out if your company is currently supporting IUA, please contact Brittany Kallman in the Registration Department at (847) 264-5963 or by email at firstname.lastname@example.org. TOTAL REGISTRATION FEE: The IUA requires full payment for registration fees by check or credit card. Payment Information (must be made in U.S. dollars) CheckCredit Card Billing Address:* ZIP:* Card Type:* --Select-- Visa MasterCard American Express Name on Card:* Card Number:* Expiration Date: (mmyy)* Card Verification #:* If paying by check, make check payable to: Indiana Urologic Association Mail payment to: Indiana Urologic Association Two Woodfield Lake 1100 E. Woodfield Road, Suite 350 Schaumburg, IL 60173 I have read, understood and agree to the electronic delivery of the data collected and payment amount.* SIGNATURE:* E-mail address Telephone Number By selecting "I Agree" I represent and acknowledge that: I have read, understood, and consented to electronic delivery of the data collected and payment entered above. I have granted authorization to IUA in association with WJ Weiser & Associates, Inc. to charge the amount indicated on the credit card provided. I am the authorized user of the credit card listed above and that the associated information entered (account holder name, account number, billing address, etc.) is accurate. I intend the act of selecting "I Agree" to be my legal signature to this agreement. This question is for testing whether you are a human visitor and to prevent automated spam submissions. Enter in the Following Security Code: 648428 Registration Cancellation and Refund Policy Registration refund requests must be submitted in writing to the IUA Executive Office no later than 1/31/2018. All refund requests will be subject to a $25 processing fee. No refunds will be made after 1/31/2018.