2021 Online Membership Application

After you complete the form, click on the "Submit" button. If you choose to use PayPal or a credit card, a 3% processing fee will be added. All contributions are non-refundable. Mailing address is PO Box 1903, Fairhope, AL 36533. Deadline for membership is March 31, 2021. (March 1 for Evergreen members)

Date

Month Day Year

Purpose of Application *

My membership Sponsor of someone else Supporter with gift towards Impact's mission

Membership Type *

New Membership Renewal Membership Rejoining (former member)

Yes, I want to be an EVERGREEN* member!

Sponsored member's name

Type of sponsor/supporter

Individual Business/organization

Business/organization name

Your first name(s) *

Last name *

Date of Birth

Optional

Mailing address *

City *

State *

Zip *

E-mail

Preferred Phone

Area Code Phone Number

Phone type

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Alternate Phone (optional)

Area Code Phone Number

Phone type

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Profession or employer (optional)

Current or former

Membership Participation Opportunities

I want to be involved in the work of Impact 100 by serving on a committee or volunteering for a done-in-a-day project- call me!

I learned of Impact through: (check all that apply)

Instagram Facebook Impact 100 website Membership Social Civic Meeting Poster/Signage Print or broadcast media A member of Impact 100

We would like a photo of you for our directory.

I have already submitted one. I would like to upload one now. I would like to take one now using my device's camera. I will submit one later.

Please select your file. We can crop or edit it as needed.

Browse Files

Submit your photo using your device camera. Be sure to click on green upload button when satisfied with photo.

Donation Amount, Payment Method, and Timing

How membership is funded (a maximum of two checks can fund a membership): *

I am individually funding my membership. I will pay a portion of my dues. I am being fully sponsored by an individual, business, or organization.

Please list the entities funding your membership *

List as sponsor/supporter in Directory? *

Yes No

Installment Plan option

I would like to pay my dues using the Installment Plan.

If dues are not paid in full by March 31, 2021, payments will be recognized as tax-deductible donations, but the donor will not be a member of Impact 100 Baldwin County. Please remit your first payment immediately, indicating your payment method in the Member Payment option field below. If paying using PayPal/Credit Card, enter the amount of this payment in the Membership Fee (1) field below, plus any additional administrative donation made with this payment in the Administrative Donation (2) field. List frequency of future payments here. *

Total amount of Administrative donation pledge, if any.

Member Payment options *

I will mail a check. I wish to pay online using PayPal or Credit Card. A 3% administrative fee will be added. If you select this option but do not complete the payment process online, your application will not be sent for processing. I would like to pay with a gift of stock. Email impact100baldwincountynews@gmail.com to request a stock transfer form. I have already submitted my payment.

Sponsor/Supporter Payment options *

By check. Online using PayPal or Credit Card. With a gift of stock. Payment already submitted.

Date member's check will be mailed: (If not immediately, indicate the date in the "other" box.) *

Immediately

Date sponsor's check will be mailed: (If not immediately, indicate the date in the "other" box.) *

Immediately

I will also apply for a non-dues match from

Amount of match

Expected date of payment

Donation Details

(1) Membership fee $

If not paying $1000, enter alternate amount

Online processing fee $

(2) Administrative donation $

Total $

Total PayPal/Credit Card payment

USD Annual Donation

Additional comments

Acknowledgment: *

I understand that my name will be published within the membership directory and at the annual meeting. I grant permission for photographs taken of me at Impact 100 Baldwin County events to be published electronically and in print for use by Impact 100 Baldwin County. Support of the Impact 100 mission by area businesses is necessary and actively encouraged. However, the use of that support by a business in a direct attempt to enhance its own revenues is prohibited. I agree not to use the membership directory for any business purpose.

* Evergreen is a new program for us, beginning with our 2021 membership campaign. Evergreen members pledge to annually renew their membership, so we start each year able to count on a core group of continuing members and focus our efforts on bringing in new members and building our grant pool. Evergreen members will receive special recognition, including Evergreen canvas totes and invitations to special events.

For Impact Use

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