Society of Urologic Oncology :: Membership Application

Membership Application

Membership Category

Active Member ($250.00)
Affiliate Member ($125.00)
Associate Member ($250.00)
Candidate Member ($0.00)
Corresponding Member ($70.00)
Allied Health Professional Corresponding Member ($125.00)

Applicant Information

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

Applicant Addresses

Preferred Mailing Address

Office Address

Include my office information in the member directory
Include my office information in the public provider directory
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

Post Graduate Training

Internship
Institution Name
City/State
Year Graduated
Residency
Institution Name
City/State
Fellowship
Institution Name
City/State

Specialty

What is your specialty?
Of what specialty board are you a diplomate?
If not a diplomate, have you been accepted to take your board?
What percentage of your practice is allocated to malignant disease?

References

Please list your Proposer and two Seconders who will send in letters of recommendation on your behalf
(All must be current active members of SUO but may not be members of the Executive Committee)

Proposer:
Seconder:
Seconder:

Please send the information listed below to:

3 letters of recommendation
Curriculum Vitae
Proof of Board Certification
Documentation of 50 major urologic oncology procedures, including a list of all major surgical cases performed during the previous year
(List should include date and type of procedure)
A copy of your letter of acceptance from the Board

Via Email: amy@wjweiser.com
Via Mail:
Membership Department
Society of Urologic Oncology
1100 E. Woodfield Road, Suite 350
Schaumburg, IL 60173
Via FAX: (847) 517-7229

TOTAL AMOUNT DUE:

Enter Security Code: 529444