Thank you for your interest in joining the CUA, please type in your information, and print it. Mail it along with a check to: CUA, 1950 Old Tustin Avenue, Santa Ana, CA 92705 Your application will be acknowledged by mail within two weeks. Your initiation fee is $100 (first years' dues). THANK YOU!

General Info
First Name: Middle: Last Name:  
Address: City:  
State: Zip Code: email:  
Phone Numbers
Work: Home: Fax:  
Practice Info
Board Certified? Year of Certification if no, are you board eligible?
if yes, year eligible
Yes No  Yes No   
Percentage of Practice Urology Medical School Year Date of birth

Other Urological Organization Membership:

Expiration Date:  
Congresional District Number (Office)    
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


NOTE: Organization dues may be deductible as professional or business expenses, to the extent allowable by law. Dues and other contributions are not deductible as charitable contributions for federal income purposes.

Please return this registration with your check for $100 to:
1950 Old Tustin Avenue
Santa Ana, CA 92705