Northwest Urological Society

Application for Active Membership

NAME: ____ Birth Date: ______________

Home Address____________________________________________________________
Phone___________________

Office Address___________________________________________________________
Phone___________________

Date of Board Certification ______________________

Medical School(s) _____________________________ Year Graduated __________

Degrees ____________________________________________

Internship (include dates):______________________________to___________________

Postgraduate Training (Urology)_____________________________________________

_______________________________________________________________________

Time practiced in present location:___________________________________________

Membership in scientific societies:___________________________________________

________________________________________________________________________

RECOMMENDED FOR MEMBERSHIP BY: 1. ____________________________

2. _____________________________
(Two NWUS members must mail a letter of recommendation to us separately from this application)

I hereby certify that the information given above Is correct to the best of my knowledge.I
hereby agree to abide by the Constitution and Bylaws of this Society in all matters referable to
the Society.
_______________________________________________________________________
(Signature) (Date)
Active Membership = $125.00/year
Membership Application = $125.00/year

ACTION OF MEMBERSHIP COMMITTEE_________________________________________________