SUO-CTC - Join us

Active – Active Members shall consist of urologists or specialists in other medical fields who are actively involved in the management of urologic cancer, and if active in patient care, enter at least one patient per year into an active trial.
Associate – Associate Members shall consist of physicians, surgeons or others who cannot fulfill the requirements of active membership but are interested in the objectives of the SUO-CTC.

Prefix:*

First Name:*

Middle Name:

Last Name:*

Suffix:

Gender:

Degree(s):

Mailing Preference:*

MaleFemale

HomeOffice

Directory Preference:*

HomeOffice

Office Address 1:*

Office Address 2:

City:*

State:

Zip/Postal Code:*

Country:*

Phone:*

Fax:

Home Address 1:

Home Address 2:

City:

State:

Zip/Postal Code:

Country:

Phone:

Fax:

Date of Birth:
(MM/DD/YYY)

Email:*

Website:

*Are you a member of the Society of Urologic Oncology? Yes No

*Do you have previous oncology clinical trial experience? Yes No

*Did you enroll at least one patient in an oncology clinical trial in the last 12 months? Yes No

*Do you have a clinical research coordinator on staff in your practice? Yes No

Practice Sub-Specialization (Check one or more)*

Interest (Check one or more)*

Bladder Cancer
Kidney Cancer
Penile Cancer
Prostate Cancer
Testicular Cancer
All/General

Adult
Pediatric
Both

Practice Type (Check one only)*
Fulltime Academics
Academics and Private Practice Blend

Fulltime Private Practice
# of Urologists in Practice:
(employees of industry are not eligible)

Clinical Trial Manager/Administrator Information
Use office address information from above?

Name of Manager/Administrator:*

Address of Manager/Administrator:*

Address 2 of Manager/Administrator:

City of Manager/Administrator:*

State of Manager/Administrator:*

Zip Code of Manager/Administrator:*

Country of Manager/Administrator:*

Phone of Manager/Administrator:*

Email of Manager/Administrator:*

SUO Clinical Trials Consortium Membership