Please input the following information. Then print, sign and mail the form with your check or credit card information.

Wisconsin Academy of Family Physicians
Legislative Involvement Fund
Contribution Form

Please place the following amount in my personal account within the Legislative Involvement Fund so I can support candidates of my choice who will fight for family practice ideals and concerns.
Contact information

Name  

Office Address  

City, State, ZIP  

Phone      Fax  

Email  

Home Address  

City, State, ZIP  

Home Phone  
Payment information
$200     $300      $500      Other $
Method of Payment:     Check         Credit Card (MC or Visa)

Credit Card #________________________________    3 digit Security Code __________    Exp. Date _______________

Cardholder Name  
Billing Address (if differs from above)  

Make checks payable to:
WAFP Legislative
Involvement Fund

Note: Signature is required to authorize contribution.

Signature ___________________________________________________

Mail or Fax to:
Wisconsin Academy of Family Physicians - 210 Green Bay Road, Thiensville, WI 53092
Phone: (262) 512-0606 - Toll Free (WI only): (800) 272-WAFP - Fax: (262) 242-1862