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AUA Masterclass in Executive Leadership Application Form

* Denotes required fields.

Deadline to apply is December 31, 2022.

Applicant Statement

Please check the box below before submitting the form.

I hereby apply for the 2023-2024 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 and fulfill all of the commitments of the 2023-2024 program. 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: *

Practice/Institution Name: *

Address: *

City: *

State/Province: *

Zip/Postal Code: *

Home Phone: *

Email: *

Fax: *

Residency Program/Years of Practice

Residency Program: *

Year of Residency Graduation: *

Program Director's Name: *

Medical School: *

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, reside within your geographical Section and will be providing letters of recommendation on your behalf.

Please be sure to personally contact your references and request them to send their letter to jmalloy@AUAnet.org or:

American Urological Association
Attn: Leadership Program/Member Services
1000 Corporate Boulevard
Linthicum, MD 21090

Reference 1

Name: *

Practice/Institution Name: *

Address: *

City: *

State/Province: *

Zip/Postal Code: *

Phone: *

Email: *

Reference 2

Name: *

Practice/Institution Name: *

Address: *

City: *

State/Province: *

Zip/Postal Code: *

Phone: *

Email: *

File Uploads

Upload any supporting files below. (Note: The filename should not should contain any punctuation, special or foreign characters.)

If you are unable to upload your documents please email them as attachments to jmalloy@AUAnet.org.

Allowed file types: PDF, PNG, JPG, JPEG, GIF, DOCX, DOC The maximum total file size for all documents should be less than 4MB.Total file size submissions exceeding 4MB may result in an error and delays with processing your application. (El tamaño máximo de archivo total para todos los documentos debe ser inferior a 4 MB. El total de envíos de archivos que superen los 4 MB puede ocasionar un error y demoras en el procesamiento de la aplicación.)

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: *

Curriculum Vitae

Please provide your C.V. Be sure to include a page on personal and professional leadership experiences, volunteerism, political advocacy, interests and a photograph (for publication purposes).

Please only upload .doc, .docx, or .pdf files: *

Commitment Agreement

As an applicant for the 2023-2024 AUA Leadership Program, my signature below indicates that, if chosen to participate, I will make myself available for all in-person and online/phone activities associated with the 2023-2024 program. Furthermore, as a chosen participant, I understand that anything less than full participation on my part could result in not graduating with the rest of my classmates at the program's conclusion.

Applicant Signature: *

SYSTEM UPGRADE NOTICE

SYSTEM UPGRADE NOTICE

AUA Masterclass in Executive Leadership Application Form

Deadline to apply is December 31, 2022.

Applicant Statement

Personal Data

Residency Program/Years of Practice

References

Reference 1

Reference 2

File Uploads

Essay

Curriculum Vitae

Commitment Agreement

American Urological Association

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