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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#:
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First Name:
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Last Name:
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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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Email Address:
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Member Type:
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Resident
Student
If you are a resident, what program do you attend?
Baton Rouge General
Lake Charles
Lafayette
East Jefferson
Kenner
St. Tammany
Bogalusa
Alexandria
Monroe
Shreveport - Core
Shreveport - Rural
Shreveport - FM/EM
If you are a resident, what year of residency are you in?
PGY1
PGY2
PGY3
I am interested in the following resident positions:
Resident Delegate to the LAFP Board of Directors
Resident Alternate Delegate to the LAFP Board of Directors
Resident Delegate to the AAFP National Conference
Resident Alternate Delegate to the AAFP National Conference
Resident Delegate to the LAFP General Assembly
Resident Alternate Delegate to the LAFP General Assembly
If you are a student, what medical school do you attend?
LSU - New Orleans
LSU - Shreveport
Tulane
Ochsner
VCOM
If you are a student, what year of medical school are you in?
MS1
MS2
MS3
MS4
I am interested in the following student positions:
Student Delegate to the LAFP Board of Directors
Student Alternate Delegate to the LAFP Board of Directors
Student Delegate to the AAFP National Conference
Student Alternate Delegate to the AAFP National Conference
Student Delegate to the LAFP General Assembly
Student Alternate Delegate to the LAFP General Assembly
Have you ever served on the Resident and Student Leadership Committee?
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Yes
No
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 National Conference and LAFP General Assembly.
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What special skills, experiences and contributions will you bring to the LAFP as a potential Board Member and/or Delegate to National Conference/General Assembly?
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What do you hope to gain/contribution from the experience?
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I understand and agree to the requirements of the positions that I am being nominated:
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Yes
No
Submit
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