Apply online or by mail

To apply for a MAPU membership online, please register through the online form. When you submit your registration you will be taken to a printable page that you can sign and submit with a check for your membership fee. You will receive an email verifying that you online account has been activated once your membership has been confirmed.

To apply for a MAPU membership by mail, please print and complete the application below

NAME:

BUSINESS ADDRESS:

BUSINESS PHONE:

HOME PHONE:

FAX#:

HOME ADDRESS:

PREFERRED MAILING ADDRESS:

HOME:

BUSINESS:

DATE OF BIRTH:

MEDICAL DEGREE:
YEAR:
SCHOOL:

UROLOGY RESIDENCY:
YEARS:
WHERE TRAINED:
MA LICENSE # :
EFFECTIVE DATE:

TYPE OF PRACTICE: (Solo, Group, Private, Salaried):

PRINCIPAL HOSPITAL AFFILIATION:

What HMO's do you belong to?:

Do you belong to any PPO's ?:
Which ones ?:

What is (are) the major issue (s) you would like MAPU to deal with ?:
Is any part of your practice of urology performed in another state outside of Massachusetts?:
If so, what state(s) ?:
Do any of your patients come to you from out of state ?:

I herby apply for membership in the Massachusetts Association of Practicing Urologists, the purpose of which is to seek equitable treatment for practicing urologists throughout the state of Massachusetts. I certify that I am either a practicing urologist with an MD or OD degree or that I am a resident in Urology in a recognized training program in the state of Massachusetts. I also certify that I am currently licensed to practice medicine in the state of Massachusetts.

Signature:
 
Date:
 
Membership fee (please enclose with application): $100 for practicing urologists, $10 if you are a resident. No charge if you are retired or semi-retired.
 
Please mail this application to:
Ms. Ginny DuLong, Executive Secretary
Massachusetts Association of Practicing Urologists
P.O. Box 9132
Waltham, MA 02454-9132