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Membership Form

Membership Application Form

Profession *

Title *

Family name *

First name *

Initials *

Gender *

Date of birth (YYYY-MM-DD) *

Nationality *

Home address

Home address *

Home postalcode *

Home city *

Home country *

Home phone *

Home fax

Home email *

Office address

Institution *

Departement

Office address *

Office postalcode *

Office city *

Office country *

Office phone *

Office fax

Office email *

Where to send the correspondence?

Send correspondence to my : *officehome

Other information

I would like to receive information on:

	Andrological Urology (ESAU - European Society of Andrological Urology)
	Cancer (EORTC - GU Group - European Organisation for Research and Treatment of Cancer -Genito-Urinary Group)
	Female Urology (ESFU - European Society of Female Urology)
	Infections in Urology (ESIU - European Society for Infections in Urology)
	Male Genital Surgery and Reconstructive Urology (ESGURS - Eur. Soc. of Genito-Urinary Reconstructive Surgeons)
	Neuro-urology (ESNU - European Society for Neuro Urology)
	Oncological Urology (ESOU - European Society of Oncological Urology)
	Paediatric Urology (ESPU - European Society for Paediatric Urology)
	Transplantation Urology (ESTU - European Society of Transplantation Urology
	Urolithiasis (EULIS - European Urolithiasis Society)
	Urological Research (ESUR - European Society for Urological Research)
	Urological Imaging (ESUI - European Society of Urological Imaging)
	Urological Pathology (ESUP - European Society of Uro-Pathology)
	Uro-Technology (ESUT - European Society of Uro-Technology)

Any notes