Please complete, print out, sign, and return the following form to:

Texas Urological Society
401 W. 15^th St.
Austin, TX 78701
(800) 880-1300, ext. 1513, or (512) 370-1513
Fax: (512) 370-1635

(Please print the following.)

Name (first, middle initial, last)
Firm Name/Institution
Name of Spouse(if applicable)
Office Address
Office Phone Number
Home Address
Home Phone Number
Preferred Mailing Address Office Home
Date of Birth  
Place of Birth
Office Fax Number
Home Fax Number
E-Mail Address
Social Security Number

Medical Education
Medical School/Graduation Date
Internship (place and dates)
Urology Residency (place and dates)
Expected Date of Completion of Residency
Licensed to practice in Texas? (give date and license number)
Are you a permanent resident of Texas? Yes No
Certified by the American Board of Urology?
Yes No  Date
Are you a member of the Texas Medical Association?
Yes No
Are you a member of the American Urological Association?
Yes No

I hereby make application to the Texas Urological Society.

Signature ____________________________________

Date_________________________________________