IMPACT 100 Pensacola (impact100pensacola.org) · 2021 Membership Form by Credit Card

Contact Information

Name

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First Name

Last Name

Middle Initial/Name

Email

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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.

Address

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

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Member Type

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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?

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Home

Work

Mobile

Home Phone

Work Phone

Mobile Phone

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

Greeters

Food for Events

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 $1,031.00 ($1000 membership contribution plus $31 processing fee.)

$

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 credit card charge.

$

2021 Membership Form Comments

Membership

Membership implies permission to use photographic, audiovisual and written works containing my image and name by IMPACT100.

IMPACT 100 Pensacola Bay Area is a 501(C)(3) under federal law and all contributions are tax deductible. FDACS Registration #CH38999. A copy of the official registration and financial information may be obtained from the Division of Consumer Services by calling Toll-Free 800-435-7352 within the State. Registration does not imply endoresment, approval or recommendation by the State

Additional Contributions

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