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LAFP Committee Interest Form

I am interested in serving on the: *

Education Committee

Legislative and Advocacy Committee

Membership Committee

Resident and Student Leadership Committee

AAFP ID#: *

First Name: *

Last Name: *

Address: *

City: *

State: *

Zip Code: *

Office Phone Number: *

Cell Phone Number: *

Email Address: *

Member Type: *

If you are a resident, what program do you attend?

If you are a resident, what year of residency are you in?

PGY1

PGY2

PGY3

If you are a student, what medical school do you attend?

If you are a student, what year of medical school are you in?

MS1

MS2

MS3

MS4

Name

Louisiana Academy of Family Physicians
919 Tara Boulevard
Baton Rouge, Louisiana 70806

Phone: 225.923.3313
Fax: 225.923.2909

Email: info@lafp.org

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