• ActiveAssociate
  Membership Type
• First Name
• Middle Name
• Last Name
• Degree(s)
• MaleFemale
  Gender
• HomeOffice
  Mailing Preference

Office

• Site/Institution Name
• Office Address
• City
• State
• ZIP/Postal Code
• Country
• Phone
• FAX

Home

• Home Address
• City
• State
• ZIP/Postal Code
• Country
• Phone
• FAX
• Date of Birth
• Email

Practice Information

• Institution/Practice Website:
• Practice Type:
• Fulltime Academics
  Academics and Private Practice Blend
  Fulltime Private Practice
• Number of Urologists in Practice:
• Specialty:
• Urology
  General Surgery
  Medical Oncology
  Radiation Oncology
  Other
• If Other, please specify
• Practice Sub-Specialization:
• Bladder Cancer
  Kidney Cancer
  Penile Cancer
  Prostate Cancer
  Testicular Cancer
  All/General
• Board Certified?:
• YesNo
• If yes, specify Board
• If no, have you been accepted to take your board exam?
• YesNo
• Do you have a current active license to practice medicine?:
• YesNo

Trial Experience

• Are you a member of the Society of Urologic Oncology?:
• YesNo
• If no, please list one SUO or SUO/CTC member as a reference
• Do you have previous oncology clinical trial experience?:
• YesNo
• Did you enroll at least one patient in an oncology clinical trial in the last 12 months?:
• YesNo
• Do you have a clinical research coordinator on staff in your practice?:
• YesNo
• ACGME Accredited Residency (or equivalent for non-U.S. applicants) completed?:
• YesNo