Certification Application - Council for Urological Interests

Lithotripsy Professional Certification Exam
Prepared by the Certification Board
of the Council for Urological Interests

Date of application*
Month
Day
Year
Applicant Name*
First Name Middle Initial Last Name
Position*
- RN
- RT
- Other
If other:*
Applicant Email Address*
Prior Certification(s):
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Facility Information
Facility Name*
Facility Phone Number*
Facility Fax Number*
Facility Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
History
Number of Lithotripsy Cases in which you have participated in the last 12 months?*
Total Number of Lithotripsy Cases in which you have participated in your career?*
Site Selection
Proposed Test Site:*
Proposed Test Date:*
MM slash DD slash YYYY
Complete form and return with:

1. Letter from Medical Director indicating minimum 50 case experience in last 12 months. (you can upload letter below)
2. Send a check for $300 made payable to: Council for Urological Interests

Mail completed information and payment to:
Joseph Jenkins, MD
Executive Director
Council for Urological Interests (CUI)
PO Box 9856
Chapel Hill, NC 27515
Questions? Email: info@urologicalinterests.org
Upload letter from Medical Director indicating minimum 50 case experience in last 12 months.
Drop files here or

Max. file size: 5 MB, Max. files: 5.
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