2005 Awards Nomination Form

Family Physician of the Year

A one-page letter of nomination must accompany this form.

I would like to nominate: __________________________________

Nomineeís address:                                                                             

 Nominatorís Name:                                                                             

 Address:                                                                                               

 Nominatorís Telephone/FAX:_____________________________________

 Nominatorís e-mail:                                                                    

Please return this form by DECEMBER 31, 2004 to:

IAFP

4756 Main Street

Lisle , Illinois 60532

Phone: 630-435-0257 / FAX: 630-435-0433

iafp@iafp.com