Membership Application

 
 
First Name:* Last Name:* Degree(s): Date of Birth:* Gender:*
 
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:   Email Address:* Preferred Mailing:*
 
         
Post Graduate Training:      
  Institution Location   Dates

Internship:

Residency:

Fellowship:

       
Board Certification:
Date:
 
         
         
* SSMR Category Desired (Check one)
$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)



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

  • Billing Address:
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  • ZIP:
    *
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  • Please note: If paying by credit card, the name WJ Weiser & Associates (the management company of the 37th Annual Specialty Review in Urology: The Chicago Review Course) will appear on your statement.
  • Card Type:
    *
  • Name on Card:
    *
  • Card Number:
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  • Expiration Date: (mmyy)
    *
  • Card Verification #:
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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

Payment amount due: