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2021-22 Membership Form - pay by paper check

Please make check payable to Impact100 DC. Mail your check to Impact100 DC, PO Box 40121, Washington, DC 20016

CONTACT INFORMATION
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First Name
Last Name
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MEMBERSHIP OPTIONS
Your $1,000 membership contribution goes in total to funding the grant. Member Plus contributions of $1,100 as well as any additional amount you enter in the third, customized option are highly appreciated and help defray essential operating expenses in this all-volunteer organization.

Any additional amount helps cover operating expenses.

Total amount of your check (ex: Member Plus + 100 extra donation = 1200). Please enter numerals only.
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country

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This directory will be for the exclusive use of our members and is not to be used for commercial or solicitation purposes.
I WOULD LIKE TO VOLUNTEER!

First Name
Last Name
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Media Release:
Mail check to:

 Impact100 DC, PO Box 40121, Washington, DC 20016