Texas Society of ACOFP

Nomination For

Family Physician of the Year

Nominee Name________________________________________

Address ______________________________________________

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                 City                                                                      Zip

Phone    ______________________________________________

Number of Years in Practice ____________________________

Please give a brief description of why you feel this person should receive Family Physician of the Year

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All nominees must be members of the Texas Society of ACOFP in good standing.

Name of person making the nomination __________________________________

Daytime Phone Number _________       ___________________________