Massachusetts Association of Practicing Urologists

After submitting this form current members will receive an email confirmation of their username and password. New applicants will be taken to a page that can be printed, signed and submitted with the membership fee ($100 for practicing urologists, $10 if you are a resident. No charge if you are retired or semi-retired). CREATE MEMBER PROFILE
*First Name
*Last Name
*Suffix
Title
*Hospital or Clinic
Department
*Address Line 1
Address Line 2
*City
*State	*Zip Code
Phone / Ext.
Fax
Gender
Date of Birth

Sub Specialty
Training
Website	http://

Hours
*Board Certification
Hospital Affiliation
Insurance Accepted
Languages Spoken
*Accepting New Patients		Handicapped Accessible
CREATE LOG IN
*Email
*Password
*Re-Enter Password
*I have read and agree to MAPU's Privacy Policy
I hereby 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.
*Required Fields