Resident and Student Nomination Application

Please fill out all of the necessary information below. If you have any questions, please contact the LAFP office at 225.923.3313.

AAFP ID#: *

First Name: *

Last Name: *

Address: *

City: *

State: *

Zip Code: *

Home Phone Number: *

Cell Phone Number: *

Email Address: *

Member Type: *

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

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

Please tell us why you would like to serve on the LAFP Board of Directors and/or be the LAFP Delegate/Alternate to the AAFP FUTURE Conference and LAFP General Assembly. *

What special skills, experiences and contributions will you bring to the LAFP as a potential Board Member and/or Delegate to FUTURE Conference/General Assembly? *

What do you hope to gain/contribution from the experience? *