Please input the following information, then print and mail the form with your check or credit card information. Or print a PDF version of the form to be completed by hand.

Wisconsin Academy of Family Physicians
-Foundation-
210 Green Bay Road
Phone: (262) 512-0606
E-Mail: academy@wafp.org 		Thiensville, WI 53092
Fax: (262) 242-1862
Web Site: www.wafp.org

I would like to help further the cause of Family Medicine in Wisconsin. Enclosed is my check in the amount of $  for unrestricted use by the Wisconsin Academy of Family Physicians Foundation.

My interests are:
Summer Externship

Research

Education & Advocacy

General Program

Endowment for the Future of Family Medicine

I have included the Wisconsin Academy of Family Physicians Foundation in my will.

Please send me additional information on wills.

Credit card contributions are also accepted.       MasterCard               Visa

Card number:    3 digit Security Code:    Expiration date: 

Card holder:            Amount of Contribution:

Signature: ____________________________________

Name:

Address:

City/State/Zip:

Billing Address (if differs from above):

Email Address:

I pledge $ to be fulfilled on / /

Please invoice for payment on / /

All gifts are tax deductible to the extent of the law.