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Name Tag Replacement Form - Payment by Check

To request an IMPACT 100 name tag replacement and pay $12 by check, please complete this form.

Contact Information
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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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Please enter your name as you would like it to appear on your name tag.
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Our standard name tag has a magnetic backing. Some of our members need a style that does not use a magnet. For those members, the options are the clip style and the pin style. Please indicate your choice of style.

Click Submit

Complete your name tag request:

Make check payable to IMPACT 100 Pensacola Bay Area, Inc. and mail to P.O. 13304, Pensacola, FL 32591-3304.