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

Personal details

For example, Dr., Prof.

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

Please use the following format: MM/DD/YYYY

Home address

Work address

Billing address