Membership Application

Membership Category

Active Member ($100.00)
Affiliate Member ($100.00)
Affiliate Member ($50.00)
Candidate Member ($0.00)

Applicant Information

Please select the category that best describes your status:
Expected Graduation Year:

Prefix
Professional Title
Designation/Degrees
First Name
Middle Name
Last Name
Suffix
Birth Date (MM/DD/YYYY)
Gender
Email
Contact Phone
Twitter Handle

Applicant Addresses

Preferred Mailing Address

Office Address

Include me in the member directory of the website.
Company Name
Office Address Line 1
Office Address Line 2
Office Address Line 3
Office City
Office State/Province
Office ZIP/Postal Code
Office Country
Office Phone
Website URL

Home Address

Home Address Line 1
Home Address Line 2
Home Address Line 3
Home City
Home State/Province
Home ZIP/Postal Code
Home Country
Home Phone

TOTAL AMOUNT DUE:

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

CheckCredit Card

Card Type
Name As It Appears on Card
Credit Card Number
Expiration Date (MMYY)
Card Verification Number
Billing Information
Billing Street Address
Billing ZIP Code

If paying by check, make check payable to: Louisiana Urological Society

Mail payment to:
Louisiana Urological Society
Two Woodfield Lake
1100 E. Woodfield Road, Suite 350
Schaumburg, IL 60173

Enter Security Code: 397032

By submitting this application, 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 Louisiana State Urological Society.