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2020 Name Tag Replacement Form - Payment by Check

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

Contact Information

First Name
Last Name


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

Please enter your name as you would like it to appear on your name tag.
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 to complete your submission.