* Denotes required fields. First Name: * Middle Name: Last Name: * AUA ID (if known): Address: * Address 2: City: * State: * Country: * Email: * Phone Number: * Please list the equipment, instruments, and/or disposables that you are willing to donate to urologists or urology institutions in underserved areas of the world. All items must be in working condition. If a matching need is found for your donation, the AUA will arrange and pay for the shipment of materials. If you would like your items to be donated to a specific cause or location, please indicate that here: Item 1 Type of Item (Include Make/Brand): Number of Items: Age of Item: Dimensions: Weight: Brief Description of Item's Condition: Item 2 Type of Item (Include Make/Brand): Number of Items: Age of Item: Dimensions: Weight: Brief Description of Item's Condition: Item 3 Type of Item (Include Make/Brand): Number of Items: Age of Item: Dimensions: Weight: Brief Description of Item's Condition: Item 4 Type of Item (Include Make/Brand): Number of Items: Age of Item: Dimensions: Weight: Brief Description of Item's Condition: