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Donor Submission Form

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:

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Donor Submission Form

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