LAMPAC Application Form
Louisiana Medical Political Action Committee

Membership in LAMPAC is limited to physician members of the Louisiana State Medical Society and members of their families and staff. Membership is entirely voluntary and not deductible for federal income tax purposes.

For more information about membership in LAMPAC, please contact Mary DuCote, Administrative Assistant, at 225.763.8500 or by email at mary@lsms.org

Select the member type. If paying by credit card, fill out the credit card information at the bottom. Print the screen and mail to the address shown at the bottom.

Regular $200
Sustainer $300
Young Physician* $100
         *First two years of practice only
Major Donor $500
Diamond $1,000
Intern/Resident $25
Student $25
Alliance $200

Enter the following information in the space provided.
Name 

Street Address, State, and Zip 


Occupation

Employer

Federal law requires political committees to report the name, mailing address, occupation and name of employer for each individual whose contributions aggregate in excess of $200 in a calendar year.  (Federal regulations require this notice, Section 11 CFR 104.7).

Please make your personal check payable to: LAMPAC
Or if paying with credit card, complete credit card number and expiration date, print form, and then sign after printing.

MC/VISA Number
Expiration Date

Signature (Sign after Printing) 
 

After completing the above information, print this page and mail to:

LAMPAC
6767 Perkins Road #100
Baton Rouge, LA 70808-4263

LAMPAC is a separate segregated fund established by the Louisiana State Medical Society. Voluntary political contributions by individuals to LAMPAC should be written on personal checks; corporate contributions can be used only for administrative purposes and state races. Funds from corporations cannot be used for contributions and expenditures in Federal elections. Contributions are not limited to the suggested amount. Neither LAMPAC or its AMA affiliate, AMPAC, will favor or disadvantage anyone based upon the amounts of, or the failure to make PAC contributions. Voluntary political contributions are subject to the limitations of FEC Regulations, Section 110.1, 110.2 and 110.5 (Federal regulations require this notice). Contributions to LAMPAC and AMPAC are not deductible as charitable contributions for Federal Income tax purposes.

 VOLUNTARY CONTRIBUTION 

THIS IS NOT A STATEMENT