Louisiana Academy of Family Physicians
919 Tara Blvd, Baton Rouge, LA 70806
Phone: 225-923-3313 Fax: 225-923-2909

2009 Support Agreement

(LAFP Federal Tax ID #72-0474962)

Louisiana Academy of Family Physicians (LAFP) accepts this commitment of support from (Company/Organization Name) for support of the LAFP's 2009 CME Meeting: 62nd Annual Assembly and Exhibition, Lake Charles, LA July 9-12, 2009

EDUCATIONAL GRANTS:
(Company/Organization) will provide an Educational Grant in the amount as follows.
ANNUAL ASSEMBLY: Amount $
Topic or Disease State

EVENT SPONSORSHIPS:
(Company/Organization) agrees to provide a Social Function and/or Production sponsorship in the amount of $ . If you wish to designate support for a particular function, please indicate the amount and activity below.

Function/Activity: Amount $
Function/Activity: Amount $

Commercial Supporter: Signer must be authorized to act on behalf of the organization, and by signing attests to reading and understanding the conditions for commercial support.

I have enclosed my check # in the amount of $ , OR my credit card information is provided below:

Credit Card Type: Card Number: 3 Digit Code: Expiration Date:

Name: Date:
Billing Address: City/State/Zip:
Phone: Fax: Email:

Signature Required: ____________________________________

LAFP Course Director/Education Chair:
Name: _____________________Signature: ________________________ Date: __________
SEE CONDITIONS FOR COMMERCIAL SUPPORT / Home