Impact 100 Membership Form

Address *

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City

State

Zip Code

Country

Membership Contribution *

Individual Member - $1,100 and have one vote Circle Member- $550 and will join one other for one vote Circle Member - $275 and will join with 3 others for one vote

For Circle Members *

Please include me with a Circle and notify me of my Circle Leader I have a Circle Leader

Circle Leader Name *

Payment Options *

Check - made payable to PCF Virginia, Memo: "Impact 100", Mail to: 48 W. Queens Way, Hampton, VA 23669 Credit Card - I understand that credit card payments will include an additional 2% to cover the credit card processing fee.

Charge my: *

VISA Mastercard American Express Discover

Name on Credit Card *

Participation - As a voting member, I am also interested in actively participating as a volunteer on the following Grants Committee: *

Recognition *

I grant permission to Impact 100 Greater Peninsula and the Peninsula Community Foundation to use my name and photo on electronic and printed donor lists, website and other promotional materials. I wish to remain anonymous for purposes of public recognition I agree that my email will be used as the primary means of communication only for Impact 100 volunteers and Peninsula Community Foundation staff.

Type full name for Signature *

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Give - Impact 100 Greater Peninsula Membership Form

2017 - 2018 Membership Form