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Volunteer Form

 

Application for consideration as a candidate for office or committee 
participationat the Northeastern Section and National AUA level 
(e.g. President-Elect, Secretary-Elect, Treasurer, Historian, and 
AUA Representative to other organizations such as AMA, ACS, 
AACU, etc.)
Name (including middle initial): *
Position Considered & Year of Office:
Address:
Address 2:
City:
State:
Zip:
Country:
Email:
Board Certification Year:
Year Joined AUA & Northeastern Section
Please list any involvement you have (past and present) with the Northeastern Section
(e.g. position(s) held and year, papers presented, meetings attended, etc.):
Please list any involvement you have (past and present) with the National Office of teh American Urological Association (e.g. position(s) held and year, papers presented, meetings attended, etc.):
Please list any involvement you have (past and present) with other urological or medical organizations (e.g. AACU, ACS, AMA, ABU, AUAF, hospitals, county and/or state organizations, etc.):
Please list any Academic Positions/ Appointments/ Committees:
Please list any non-medical leadership affiliations or involvement (e.g. philanthropic, civic, service clubs, religious, commercial, political, etc.):
Briefly state why you should be considered as a candidate for this position:


 

 
Northeastern Section of the AUA · 1000 Coporate Boulevard · Linthicum, Maryland 21090
Phone: 410-689-4025 · Fax: 410-689-3837 · E-mail: nsaua@auanet.org · Website: www.nsaua.org