Connect with Us:
≡
Open menu
HOME
PHYSICIANS
RESIDENTS
MEDICAL STUDENTS
Log In
LaFamPac Donation Form
Contact Information
AAFP ID#:
*
Member Type:
*
Active
Life
Resident
Student
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
If you marked other, how much would you like to donate?
Is this a recurring donation? (choose one)
*
One-time donation
Monthly donation
If you marked monthly donation, how long would you like to make this monthly donation?
Payment Information:
Credit Card Type
*
Mastercard
Visa
American Express
Discover
Cardholder's Name
*
Credit Card Number
*
Expiration Date
*
Security Code
*
Billing Address:
*
City:
*
State:
*
Zip Code:
*
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
No
Submit
© 2024 LAFP | Web Design by
Bruner and Company
Member Login
Username
Password
Remember Me
Forgot your password?
Forgot your username?
