IMPACT 100 Pensacola (impact100pensacola.org) · 2019 Membership Form by e-CHECK

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2019 Membership Form by e-CHECK

To join for 2019 please complete the form below allowing you to pay by e-CHECK.

Contact Information

Name

First Name

Last Name

Middle Initial/Name

If you need to change your email, please type in the new email in the Comment Block at the end of this form.

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Member Type

First time member

Renewing member: You were a member last year

Rejoining member: You are a returning member

Referred by:

How did you learn about IMPACT 100?

Name for IMPACT 100 Name Tag

Preferred Phone Number?

Home

Work

Mobile

Home Phone

Work Phone

Mobile Phone

I would like to volunteer to help in the following areas (optional):

Welcome Committee

Food for Events

Phone Calls

Volunteer Professional Expertise:

I prefer correspondence from IMPACT 100 Pensacola Bay Area, Inc. be delivered by:

Email Preferred

Mail Preferred

MEMBERSHIP AMOUNT: I authorize payment for 1000.00 for my membership contribution.

Additional Contributions

No voting rights are given for any donations other than full membership. When possible IMPACT 100 applies honorariums 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.

I would like to make an additional donation:

Administrative costs like postage, printing, website and database maintenance do not come out of the membership dues so additional contributions are welcomed!

To help with administrative costs.

In honor of

In memory of

Name

Enter Name of the Person this donation is IN MEMORY OF or IN HONOR OF

DONATION AMOUNT. Add the following donation to my e-CHECK, if any.

2019 Membership Form Comments

Additional Contributions

Click Submit to complete your submission.