Indiana Urologic Association, Inc.

• First Name:*
• Last Name:*
• Degree(s):
• E-mail Address:*
• Gender:*
• MaleFemale
• Preferred Mailing Address:*
• HomeOffice
• Birthdate:* (mm/dd/yyyy)
• / /
• Office Address:*
• City:*
• State:*
• ZIP Code:*
• Country:*
• Office Telephone:*
• Office FAX:
• Home Address:*
• City:*
• State:*
• ZIP Code:*
• Home Telephone:*

Membership Type:*

• Active Membership $100.00 USD
• Qualifications: Active Membership in this Society is limited to licensed physicians of who reside and practice Urology in the state of Indiana and have an unrestricted license to practice medicine. $100.00 USD payment of Annual Dues is required.
• Affiliate Membership $100.00 USD
• Qualifications: Affiliate Membership in this Society includes licensed physicians in related fields of medicine and science who cannot qualify for active membership and Non-physicians who, by their professional or personal accomplishments have contributed significantly to medicine in general or the specialty of urology. $100.00 USD payment of Annual Dues is required.
• Candidate Membership $0.00 USD
• Qualifications: Candidate Membership in the Society is limited to residents in an accredited Urology training program within the state of Indiana. Such membership will terminate with completion or discontinuation of such residency training. There are no annual dues.

---

What area of subspecialty: (check all that apply)

AcademicsEndourologyFemale UrologySexual Medicine
General Urology AdultsMale InfertilityPediatric UrologyUrologic Oncology

Due to FCC regulations we need your permission to fax or e-mail you any information regarding your membership benefits and services.

I give permission to the IAU to fax/e-mail me registration forms, dues statements, and other solicitations.

I hereby certify that the information on this application is correct. If accepted for membership, I hereby agree to abide by the Constitution and Bylaws of the Indiana Urologic Association, Inc.

• APPLICATION FEE:

Payment Information (must be made in U.S. dollars)

• --Select Card-- Visa MasterCard American Express

• I have read, understood and agree to the electronic delivery of the data collected and payment amount.
• SIGNATURE:
• 
  
• 
  

• By selecting “I Agree” I represent and acknowledge that:

  1. I have read, understood, and consented to electronic delivery of the data collected and payment entered above.
  2. I have granted authorization to IUA in association with WJ Weiser & Associates, Inc. to charge the amount indicated on the credit card provided.
  3. 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.
  4. 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: 566030