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AUA Leadership Program Application Form

* Denotes required fields.

Applicant Statement

Please check the box below before submitting the form.

I hereby apply for the 2025-2026 AUA Leadership Program. I am an Active member in good standing of the American Urological Association and my appropriate geographical Section, and I am 15 years or less out of training (fellowship can be included). I am also currently licensed to practice without restriction. I agree, if chosen, to participate fully in the program and fulfill all of the commitments outlined in this application. I understand that there will be no out-of-pocket expenses. I attest that all statements made in this application are complete and true to the best of my knowledge.

Personal Data

First Name: *

Middle Name:

Last Name: *

Credentials: *

Practice/Institution Name: *

Primary Address: *

City: *

State/Province: *

Zip/Postal Code: *

Home Phone: *

Email: *

Residency Program/Years of Practice

Residency Program: *

Year of Residency Graduation: *

Program Number of Years Practicing Urology: *

References

Please provide the names and contact information for two members in good standing of the AUA who can attest to your leadership abilities and will provide letters of recommendation on your behalf. The names entered below will automatically receive an email with request for a letter of recommendation upon submission of this form.

Letters of recommendation are due no later than January 6, 2025 and should be submitted to aualeadership@AUAnet.org.

Reference 1

Title: *

Name: *

Practice/Institution Name: *

Address: *

City: *

State/Province: *

Zip/Postal Code: *

Phone: *

Email: *

Reference 2

Title: *

Name: *

Practice/Institution Name: *

Address: *

City: *

State/Province: *

Zip/Postal Code: *

Phone: *

Email: *

Essay

Provide a personal statement describing why the AUA Section should select you to participate in the AUA Leadership Program. Expand on how your characteristics and experience have prepared you for this next step in your career and your commitment level to serving the AUA in the future. Tell us your professional interests, AUA interests, what you hope to gain, etc. Limit your essay to 500 words, typed and double spaced.

Please only upload .doc, .docx, or .pdf files. * If you are unable to upload your documents please email them as attachments to aualeadership@AUAnet.org. Please be sure to include your full name in the subject line of your email.

Curriculum Vitae

Please provide your C.V. along with an expanded page on personal and professional leadership experiences (both professional and volunteer).

Headshot

Please upload a hi-res photo (uncropped) up to 4MB.

Please only upload .jpg or .png files. * If you are unable to upload your headshot please email it as an attachment to aualeadership@AUAnet.org. Please be sure to include your full name in the subject line of your email.

Applicant Signature: *

SYSTEM UPGRADE NOTICE

AUA Leadership Program Application Form

Applicant Statement

Personal Data

Residency Program/Years of Practice

References

Reference 1

Reference 2

Essay

Curriculum Vitae

Headshot

American Urological Association

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