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Applicant Information Form


Valid through June 2008
for Postgraduate Residency Training in Urology
(Maintained by the AUA Member Services)

Date you can begin:

Check all levels
of residency that apply:

PGY-1
PGY-2
First year Urology
Second year Urology
Third year Urology
Fourth year Urology

Last Name:

First Name:

Middle Name:

Present Address:

City:

State:

Zip:

Permanent Address:

City:

State:

Zip:

Home Telephone:

E-mail:

Medical School/
Hospital Telephone:

Date of Birth:

Place of Birth:

Citizenship:

Type of Visa:

ECFMG Number:


Nearest Relative or Individual Always Able to Contact You:

Name:

Relationship to You:

Address:

City:

State:

Zip:

Telephone:


Medical School:

Name:

City:

State or Country:

Dates Attended:

From:

To:

Degree Received:

Graduation Date:


Medical School:

Name:

City:

State or Country:

Dates Attended:

From:

To:

Degree Received:

Graduation Date:


Undergraduate Institution:

Name:

City:

State or Country:

Dates Attended:

From:

To:

Degree Received:

Graduation Date:


Previous Residency Training:

Hospital:

State:

Specialty:

Dates:

From:

To:

Hospital:

State:

Specialty:

Dates:

From:

To:

Professional Training
Other than Residency:

This form will be thrown out on July 1 each year. If you wish to be listed again you must fill out a new form. Do not send any other information. It will be discarded.