CUA Application    

Thank you for your interest in joining the CUA, please type in your information,
and either submit electronically or print and fax the form below to (714) 550-9234. 
Your application will be acknowledged by mail within two weeks.
Your initiation fee of $70 (first years' dues) will be billed. THANK YOU!

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NAME
OFFICE ADDRESS
CITY ZIP CODE
OFFICE PHONE FAX
CONGRESSIONAL DISTRICT NUMBER (OFFICE)
RESIDENCE ADDRESS
CITY ZIP CODE
RESIDENCE PHONE
EMAIL ADDRESS

BOARD CERTIFIED? YES NO YEAR OF CERTIFICATION
IF NO, ARE YOU BOARD ELIGIBLE YES YEAR NO
MEDICAL SCHOOL YEAR
OTHER UROLOGICAL ORGANIZATION MEMBERSHIP:
APPLICANT’S BIRTH DATE
PERCENT OF PRACTICE UROLOGY OTHER

I hereby make application to the California Urological Association for Active
Membership and I agree to abide by the Articles of Incorporation and Bylaws.

Signed Date

Send mail to info@cuanet.org  with questions or comments about this web site.
Copyright © 2002 California Urological Association, Inc
Last modified: June 19, 2000