Online Membership Application Membership Application New York Section - AUA, Application for membership Step 1 of 2 50% Online ApplicationI am applying for:* Active Membership ($100 application fee) Associate Membership ($100 application fee) Affiliate Membership ($50 application fee) Requirements for Active Membership are as follows: Possession of an unlimited license to practice medicine and surgery in the state of the applicants residence Practice in the geographical boundaries of the New York Section Possession of an MD or DO degree and completion of an accredited urology residency Limitation of practice to the specialty of Urology Certification by the American Board of Urology (ABU) Recommendation for membership by two (2) voting members of the AUA and a copy of applicants curriculum vitae. Requirements for Associate Membership are the same as Active Membership, except for board certification. Candidate members eligible for Fast Tract Associate status: Associate Membership will be offered to all candidate members who have passed the qualifying examination (Part I) of the American Board of Urology Non-members eligible for Associate status: Associate Membership is available to non-member urologists who are practicing within the geographic boundaries of the Section but are not certified by the American Board of Urology. Requirements for Affiliate Membership are as follows: Non-Urologist MDs or Doctors of Osteopathy who are significantly contributing to the field of Urology through clinical practice are eligible for Affiliate membership in the New York Section. In addition to completing the application, we require applicants to submit the following: $50.00 (U.S. Dollars) nonrefundable application fee. A copy of your curriculum vitae One letter of endorsement from an AUA voting (Active) member attesting to your moral, ethical and professional competence. A personal statement describing your significant contributions to the specialty of urology and the reason why you are interested in joining the NYS. Acknowledge Terms of Membership Application* I also understand that following the application process and favorable review and approval by the NYS board of directors, my complete application will be forwarded to the American Urological Association offices. It will then be reviewed for national membership at the next AUA board meeting. General InformationName* First Last Email* Enter Email Confirm Email DegreeGender Female Male Office Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred Mailing Address Office Home Preferred Directory Address Office Home Area(s) of Expertise*0 of 500 max characters Are you a legal citizen where you practice?*YesNoDate of Birth MM slash DD slash YYYY Place of BirthDate of Licensure MM slash DD slash YYYY Place of LicensureName of SpouseEndorsementsAll applicants must provide name and address of Active or Senior member(s) of the Section who will endorse this application in accordance with Section RequirementsSponsor 1 Name*Sponsor 2 Name*Letters of Recommendation Drop files here or Select files Accepted file types: pdf, doc, docx, txt, Max. file size: 5 MB, Max. files: 5. Education, Training and Professional ExperienceMedical SchoolDegree(s) EarnedDate of Graduation MM slash DD slash YYYY Urology Residency ProgramName of Urology Resident ProgramDates of Urology Residency Program If your urology residency program approved by the Accreditation Council for Graduate Medical EducationYesNoAdvanced Post-Urological TrainingInstitution InformationName of InstitutionCityDates Where have you practiced since completing your urological residencyLocationDates Hospital Appointments Currently HeldHospital InformationHospital NameLocation Teaching Positions HeldPositions (Past or Present)TitlePosition Certification of ApplicantApplicant certifies:* I certify that to the best of my knowledge the information which I have provided is true and complete.