PAC Donation Form

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LaFamPac Donation Form

Contact Information

AAFP ID#: *

Member Type: *

First Name: *

Last Name: *

Address: *

City: *

State: *

Zip Code: *

Home Phone Number: *

Cell Phone Number: *

Email Address: *

*Federal election law requires LaFamPac to report the name, address, occupation, and name of employer for anyone who contributes $200.00 or more.

Occupation:

Employer Name:

Employer Address:

City:

State:

Zip Code:

Office Phone Number:

Donation Information:

Donation Amount: (choose one) *

$25

$50

$100

$250

$500

$1,000

Other

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Payment Information:

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Disclaimer:

I have read and agree to the following:

I am aware of the political purposes of LaFamPac; understand that contributions to LaFamPac are purely voluntary and that these suggested contribution amounts are only guidelines. I further understand that I will not be favored or disadvantaged by reason of the amount of my contribution or a decision not to contribute. I further understand that contributions to LaFamPac are not tax deductible for Federal Income Tax purposes. *

Yes

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Email

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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