American Urological Association
2016 Gold Cystoscope Award Nomination Form
For nominations submitted by Urology Chairs and Program Directors
The Gold Cystoscope Award may be presented annually to a urologist who has distinguished him/herself by outstanding contributions to the profession within ten (10) years of completing residency training (residency must be completed no earlier than June 2006).
Please complete each section of this form in its entirety and attach an abbreviated CV (no more than 3 pages in length). Only nominations received from Urology Program Chairs & Directors will be accepted. Questions regarding the nomination process may be directed to Beverly Mannion, AUA Committee & Society Affairs at firstname.lastname@example.org.
Deadline to receive nominations is October 31st