About President's Welcome Mission Statement Board of Directors Past Presidents Bylaws Contact Patients What Is Male Infertility? Causes of Male Infertility Diagnosing Male Infertility Treatment for Male Infertility Surgical Treatment for Male Infertility Medical and Other Treatments Patient Support Resources Patient Education Forum Fertility & Cancer Professionals Male Infertility Guidelines Participating Organizations Research Traveling Fellowship Programs The SSMR & SMSNA Traveling Fellowship Program Belker Traveling Fellowship Fellowship Opportunities Onco Fertility for Physicians Job Board Membership Member Benefits Categories of Membership Apply for Membership Member Portal Member Dues Member Directory Meetings & Webinars Upcoming Meetings Past Meeting Materials Past Webinars Awards Distinguished Reproductive Urology Award Arnold Belker Traveling Fellows SSMR & SMSNA Traveling Fellows Industry Partners News & Research Recent News & Events Newsletters Latest Research Research Spotlight Find a Doctor Directory Opt-In Instructions Fertility & Cancer Information for Physicians Information for Patients Member Benefits Categories of Membership Apply for Membership Member Portal Membership Application First Name: Last Name: Degree(s): Date of Birth: Gender: MaleFemale Email Address: Preferred Mailing: HomeOffice Office Address: Office City: Office State: Office ZIP/Postal Code: Office Country: Office Telephone: Office FAX: Home Address: Home City: Home State: Home ZIP/Postal Code: Home Country: Home Telephone: Home FAX: Post Graduate Training Institution Location Dates Internship: Residency: Fellowship: Board Certification: SSMR Category Desired (Check one) ACTIVE MEMBERSHIP — $125.00 USD (Annual Dues / Application Fee) Pays full dues and has voting privileges. Qualifications:Individuals interested in male reproductive health with: (please check all that apply, must fulfill at least one) At least 20% of clinical practice or research effort must be in the area of fertilityAt least 3 months of basic or clinical training in male reproductive surgery or medicineDemonstrated an interest in male reproduction by attending 3 SSMR meetings, or 2 SSMR meetings and a subject-oriented seminar dealing with infertility sponsored by the AUA (completed within a 5-year period) RESIDENT/FELLOW/POSTDOCTORAL STUDENT MEMBERSHIP Dues waived and may not vote. Additional Qualification: Letter of recommendation from program director required. Expected graduation date: (Letter of recommendation from program director required) PAYMENT AMOUNT DUE: Payment Information (must be made in U.S. dollars) CheckCredit Card -- Select Card -- Visa MasterCard American Express If paying by check, make check payable to: Society for the Study of Male Reproduction Mail payment to: Society for the Study of Male Reproduction 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: 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 SSMR 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.