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Please complete form and include with supporting materials. Send via U.S. mail or email to Ragan LeBlanc Louisiana Academy of Family Physicians 919 Tara Boulevard Baton Rouge LA 70806 rleb lanc lafp.org DEADLINE March 1 2017 Family Physician of the Year 2017 Nomination Form Date Submitted Physician s Name Home Address City State Zip Office Address City Physician s Phone E-mail Address Home Office Fax Physician s Residency Program Board Certified Yes Member in good standing No LAFP Member...
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