REGISTRATION FORM

PERSONAL INFORMATION
 
Last Name
First Name
ID Number
Documento
Address
City
State
Zip Code
Telephone
Fax
E-mail
PROFESSIONAL INFORMATION
   
Graduation
Institution
Department
License (NR)
Professional Association
ACADEMIC INFORMATION
   
Post-Graduation

School
Class
Publications

MEDICAL CERTIFICATION
   
For How Long Working in Uro- Oncology:
Time Devoted to Uro-Oncology:
Medical Society Membership:

DISCLOSURE
1. Have you ever had your medical license suspended or terminated?
2. Have you ever had hospital staff privileges denied, reduced in scope, or rescinded for cause?
Sí   No
3. Have you ever had disciplinary action taken against you at any time by a medical society, academic institution or government agency?
Sí   No
4. Have you ever been convicted of or pleaded guilty to a felony or other serious crime?
Sí   No
Applicant's Authorization of Release of Information
I hereby consent to the release by any hospital, educational institution, governmental agency, physician, professional society,or other person possessing or requiring the same, whether or not listed above, of any and all information in any way pertaining to my personal character, training, experience or professional competence.

I agree that communications of any nature made to the UROLA regarding my fitness for membership may be made in confidence. I hereby release from any liability any and all individuals and organizations or their authorized representatives who provide this information in good faith and without malice subject to this consent.

I hereby release from all liability the Uro-Oncology Latin American and any and all individuals for their acts if performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications.

I hereby certify that all information recorded on this application and any attached documents is accurate and supports my qualifications for membership in the Uro-Oncology Latin American Association for which I now apply. I hereby agree that the Uro-Oncology Latin American Association may verify any of the above data. If elected, I agree to conform to the Constitution and Bylaws of the Uro-Oncology Latin American Association.