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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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Allied Health Professions Membership Application Form
 
You are here: Membership > Allied Health Professions 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

Profession
Nurse Practitioner
Physician's Assistant
Administrative Personnel

Medical Education
Professional School/Graduation Date
Internship (place and dates)
Residency (place and dates)
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

Type of Practice
    Other (specify)

If in private practice, are you in:


Do you limit your practice to urology? Yes   No
Please list the hospitals where you have staff appointments (two per line):


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