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2023 Membership Form by PAPER CHECK

To join for 2023 please complete the form below which will notify IMPACT 100 that you plan to pay by a paper check which can be mailed or dropped off with an IMPACT Board Member.

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First Name
Last Name

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If you need to change your email, please type in the new email in the Comment Block at the end of this form.
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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How did you learn about IMPACT 100?

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Type in the amount with NO special characters; i.e. 1000

Name of the financial institution or company who will be sending the check if not paying with a personal check

Additional Contributions

These donations are in addition to your $1000 membership.

No voting rights are given for any donations other than full membership. When possible IMPACT 100 applies In Honor Of/In Memory Of and sponsorships to fund grants, although the Board of Directors of IMPACT 100 Pensacola Bay Area has the discretion to use any donations other than full membership for administrative costs or as grant money.
Administrative costs like postage, printing, website and database maintenance do not come out of the membership dues so additional contributions are welcomed!

Enter the name of the Person this donation is In Honor Of or In Memory Of


Membership

Membership implies permission to use photographic, audiovisual and written works containing my image and name by IMPACT100.

IMPACT 100 Pensacola Bay Area is a 501(C)(3) under federal law and all contributions are tax deductible.  FDACS Registration #CH38999.  A copy of the official registration and financial information may be obtained from the Division of Consumer Services by calling Toll-Free 800-435-7352 within the State.  Registration does not imply endoresment, approval or recommendation by the State

Make checks payable to IMPACT 100 Pensacola Bay Area, Inc. and mail to P.O. Box 13304, Pensacola , FL 32591-3304.
 
Click Submit to complete your submission.