Impact 100 Jersey Coast · Membership Pledge Form FY21

Is this a new membership or a renewal?

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New

Renewal

Name

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First Name

Last Name

Email Address

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Preferred phone number

*

Mailing Address

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Birthday

*

(mm/dd/yyyy)

Occupation

Name of Employer

Spouse's Name

Spouse's Employer

Eligible for Match?

Our Matching Gifts Coordinator can help determine if funds are available through an employer's matching gift program and can help you initiate the process. All matching funds provide vital support to Impact.

Yes, my employer.

Yes, my spouse's employer.

No.

I'm not sure.

How I learned about Impact 100 Jersey Coast

First Name

Last Name

First Name

Last Name

First Name

Last Name

Other (Member of another Impact, magazine article, social media, etc.)

Pledge Commitment

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I commit to become a Voting Member of Impact 100 Jersey Coast by making a tax-deductible donation of $1,100. ($1,000 for grantmaking; $100 will cover membership activities and CFNJ* fund management fee).

Preferred Donation Method

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Check

Credit Card

Fund Transfer ( eg Donor Advised Fund, IRA, etc)

Third Party (Employer, Outside Sponsor, etc.)

If your donation method is via a Fund Transfer or a Third Party, please provide the name of the fund manager or third party.

Expected Payment Date

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The Membership Team will invoice you before this date. In order to have voting rights at the Annual Meeting, your nonrefundable membership contribution must be received by March 15th of the Membership Year. At this time we are unable to accept membership donations in installments. Your full membership donation of $1,100 must be received before March 15th to be included in that year’s grant award process.

Volunteer Interest

I am interested in hosting a member recruitment event.

Please share additional information about your background, experience, and/or volunteer interest:

Demographic Information

Race

Select all that apply.

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian of Other Pacific Islander

White

Ethnicity

Select One

Hispanic or Latino

NON Hispanic or Latino

Confidentiality Agreement & Photo Release

I will not disclose confidential information acquired in connection with the work I do on behalf of Impact Jersey Coast. I agree not to share members’ names outside the organization and understand that the membership list will be printed and distributed to other members. I agree that my image may be used in photographs to promote Impact Jersey Coast via its website, on social media, and in other materials. If you do not wish to be included in the listing, please email: membership@impact100jerseycoast.org.

Terms of Agreement

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I have read and agree to all terms outlined in the Impact 100 Jersey Confidentiality Agreement.

*The Community Foundation of New Jersey is a nonprofit 501(c)(3) public charity, and all contributions are tax-deductible to the fullest extent of the law.