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LAFP Legislative Key Contact Form
Please fill out all of the necessary information below. If you are unsure of who your legislator is, please visit the Advocacy Action Center on the LAFP website and input your zip code information. If you have any questions, please contact the LAFP office at 225.923.3313.
AAFP ID#:
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First Name:
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Last Name:
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Email Address:
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Member Type:
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Active
Resident
Student
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
Home Information
Address:
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City:
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State:
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Zip Code:
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Home Phone Number:
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Cell Phone Number:
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Office Information
Street Address (line 2):
Office Phone Number:
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Fax Number:
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Legislative Information
LA - House District #
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LA - House of Representative Member:
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Relationship:
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Business Associate
Church
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Family
Friend
Social
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US - House District #
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US - House of Representative Member:
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Relationship:
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Business Associate
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Family
Friend
Social
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Other
LA - Senate District #
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LA - Senate Member:
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US - Senate District #
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US - Senate Member:
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Relationship:
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Family
Friend
Social
Volunteer
No Relationship
Other
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