Society of Urologic Prosthetic Surgeons

Member Application

Membership Category

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

Applicant Information

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

Applicant Demographics

Please select the category that best describes your status:
Expected Graduation Year:
Program Name:
Are you a member of the AUA?
What is your AUA member type?

Applicant Addresses

Preferred Mailing Address

Office Address

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

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: Society of Urologic Prosthetic Surgeons.

Mail payment to:
Society of Urologic Prosthetic Surgeons.
Two Woodfield Lake
1100 E. Woodfield Road, Suite 350
Schaumburg, IL 60173

Enter Security Code: 827413

PLEASE NOTE