Membership Application

This form can be used to apply for CUCOG membership. Your membership application will be reviewed within 5 business days and you will be notified of acceptance by email.

All data submitted on this form will be processed on a Secure Server (SSL), which is owned and maintained by the company managing the CUCOG Executive Office 'Status Plus B.V.' in The Netherlands. For more information please contact us by phone +1 (952) 247-4889 or e-mail cucog@cucog.org.

Personal details

Gender

Title

For example, Dr., Prof.

First name*

Middle name

Last name*

Suffix

For example, Jr., Sr., II etc.

Designation

For example, MD, PhD etc.

Organization*

E-mail*

How did you hear about us?

Assistant Email Address*

Dept. Administrator/Program Director Name*

Dept. Administrator/Program Director Email Address*

Dept. Administrator/Program Director Phone*

Date of Chair Appointment (for membership log tracking purposes only)*

Please use the following format: MM/DD/YYYY

Name of Previous Department Chair*

Preferred mailing address*

Please choose your billing address*

Home address

Organization

Department

Address *

ZIP Code *

City *

Country*

State/Province

Telephone

Area code

Number

Ext.

Cell

Area code

Number

Fax

Area code

Number

E-mail

Website

Work address

Organization

Department

Address *

ZIP Code *

City *

Country*

State/Province

Telephone

Area code

Number

Ext.

Cell

Area code

Number

Fax

Area code

Number

E-mail

Website

Billing address

Organization

Department

Address *

ZIP Code *

City *

Country*

State/Province

Telephone

Area code

Number

Ext.

Cell

Area code

Number

Fax

Area code

Number

E-mail

Website

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