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Shari Noonan, CAE, CMP
Executive Director
Phone: (512) 370-1513
Jenny Holkesvik
Membership Coordinator
Phone: (512) 370-1513


CONTACT

Texas Urological Society
401 W. 15th St.
Austin, TX 78701-1680
Phone:(512) 370-1513
Fax:(512) 370-1635

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Texas Urological Society, Inc.
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Associate Membership Application Form
 
You are here: Membership > Associate Membership Application Form

Please fill out and submit the following form.

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

(Please fill out the following, then click 'Submit Application' below.)


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

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

By submitting this form, I hereby make application to the Texas Urological Society.