Membership Category Active Membership ($1,650.00) Membership is open to any urology training program accredited by the Accreditation Council of Graduate Medical Education (ACGME). Active membership applications must be requested and completed by the applicant prior to consideration for membership. Institution Information Include this institution in the member directory of the website. Institution Name Institution Address Line 1 Institution Address Line 2 Institution Address Line 3 Institution City Institution State Institution ZIP Institution Phone Website URL Institution Staff Program Director Full Name Program Director Email The Program Director will be responsible for confirming the institution’s individual list yearly. Urology Chair Full Name Urology Chair Email Program Coordinator Full Name Program Coordinator Email Billing Contact Full Name Billing Contact Email Additional Staff All faculty members at a member institution are eligible to take advantage of SAU member benefits. Please provide a list of the institution’s urology faculty. If you would prefer or there are more than five additional faculty members, you may upload a list, but please include each individual member’s full name and unique contact email address. Membership List Upload: (Allowed filetypes: XLS, XLSX, DOC, DOCX, RTF, PDF) Member Full Name 1 Member Email 1 Member Full Name 2 Member Email 2 Member Full Name 3 Member Email 3 Member Full Name 4 Member Email 4 Member Full Name 5 Member Email 5 TOTAL AMOUNT DUE: Payment Information (must be made in U.S. dollars) CheckCredit Card --Select Card-- Visa MasterCard American Express Card Type Name As It Appears on Card Credit Card Number Expiration Date (MMYY) Card Verification Number Billing Information Billing Street Address Billing ZIP Code If paying by check, make check payable to: Mail payment to: Society of Academic Urologists Two Woodfield Lake 1100 E. Woodfield Road, Suite 350 Schaumburg, IL 60173 Signature Email Address Telephone Number Signature Date I Agree that I represent and acknowledge that: I have read, understood, and consented to electronic delivery of the data collected and payment entered above. I have granted authorization to SAU in association with WJ Weiser & Associates, Inc. to charge the amount indicated on the credit card provided. I am the authorized user of the credit card listed above and that the associated information entered (account holder name, account number, billing address, etc.) is accurate. I intend the act of selecting “I Agree” to be my legal signature to this agreement. Enter Security Code: 616800