FMIG 2021 National Conference Informational Meeting Submission Form

INSTRUCTIONS:
Please complete the following to be eligible to receive funds from the AAFP for your FMIG-hosted National Conference informational meeting. Complete this online form and send your attendee list to Keshia McAfee at kmcafee@aafp.org.

1. Medical school information *This question is required.

. *This question is required.

Medical school name
Medical school location
Main or regional campus?
Student organization name

2. FMIG student leader primary contact *This question is required.

Name
Class year
Email address

3. FMIG faculty advisor primary contact *This question is required.

Name
Professional Title
Email address

4. Please indicate how funds should be addressed *This question is required.

Organization
Tax identification number
Attention to
Street address
City
State
Zip code

5. To receive $100, all of the following eligibility criteria must be fulfilled.

Presented the AAFP National Conference powerpoint presentation at a FMIG meeting during spring 2021.
Submitted a copy of attendees to the AAFP. (Email to kmcafee@aafp.org)
Submission form completed no later than May 31, 2021.

*This question is required.

I verify that all eligibility criteria has been completed.