Nomination & Application Form 19th SUPS/SMSNA Surgical Lab Friday, November 13, 2020 San Diego, CA The deadline to submit this form is July 31, 2020. denotes required field The deadline to submit an application for the Surgical Lab was July 31, 2020. Candidate Information First Name: Last Name: Year of residency: for 2020-2021 academic year Have you participated in a SMS/SUPS surgical lab in the past?: YesNo Gender: FemaleMale Name of Primary Institution: Address: City: State/Country: (select country) Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia-Herzegovinia Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo (Dem. Republic) Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey and Alderney Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Island of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea (Democratic Republic of) Korea (Republic of) Kosovo Kuwait Kyrgyz Republic Laos Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldavia Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua-New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Re union Republic of Dominica Romania Russian Federation Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay USA Uzbekistan Vanuatu Vatican (Holy See) Venezuela Vietnam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe (select state) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP code: Candidate Email: Resident Coordinator Email: (if applicable) Phone: ()-First three digitsSecond three digitsLast four digits Name of secondary institution: (if applicable) Program Contacts Program Chair/Mentor Name: Program Chair/Mentor Email: Is your Program Director/Mentor a member of SUPS or SMSNA?: YesNo Program Director Name: Program Director Email: Candidate Questions Have you submitted an abstract to the 21st SMSNA Fall Meeting?: YesNo Does your institution have a Prosthetic Surgeon on faculty?: YesNo Name of Prosthetic Surgeon on staff: (if applicable) Number of penile implants performed during residency to date: Number of artificial urinary sphincters performed during residency to date: Number of testicular implants performed during the residency to date: Candidate Statement Candidate’s Statement of Interest in attending the surgical lab: By submitting this form, I understand that I am confirming that all the information provided above is valid and correct.