1 Step 12 Step 23 Step 3 We look forward to having you join us as a member! The full $1,150 contribution to participate in the next membership grant cycle is due by December 1st. All donations are tax deductible. Please fill out the sections below and click JOIN at the end of the form. All fields marked with an * are required to be completed for the form to submit properly.Contact InformationName*Please type your name below as you would like it to appear in the membership list. First Last Your Email*Email will be the primary way we will contact you. Please note, your email is required, however if there are no updates to your address or phone, please click Next to go to the next page. Address Address - House Number & Street City State Zip Code Preferred PhoneEnter up to 3 in preferred order Mobile Home Work Mobile Phone NumberHome Phone NumberWork Phone NumberAdditional InformationDate of Birth EmployerNew Members: How Did You Hear About Impact (check all that apply) Social Media Word of Mouth Impact 100 Philly Website From a Member Member(s) Name Confidentiality & Conflicts of InterestConfidentiality & Conflicts of Interest*CONFIDENTIALITY: I will not disclose confidential information acquired in connection with the work I do on behalf of Impact100. I agree, each year I am a member, not to share members' names outside the membership. CONFLICTS OF INTEREST: To insure a fully transparent grant selection process, I will disclose to the Impact100 Philadelphia board of directors, each year I am a member, any potential conflict of interest that I may have with any Impact100 applicants. I understand that I may be asked to refrain from discussion on any topic where a potential conflict of interest arises. In addition, I will not attempt to gain an advantage for or to persuade other members to vote for any particular grant applicant. BY TYPING MY NAME BELOW, I acknowledge I have read and understood these statements. Payment InformationHow are you making your donation to Impact100 Philadelphia?*Mail a CheckCredit Card or PayPalInstallment PaymentsBank Transferfor PayPal Acct Holders$35 will be added to cover the online processing feePlease Mail Your Check To: Impact100 Philadelphia PO Box 275 Wynnewood, PA 19096 When you join or renew this year, please consider adding something extra to your $1,150 membership contribution. Every dollar helps! Would you like to make an additional donation to the general operating fund?$50$150$250OtherPlease enter your donation amount.Your total today is: Price: $0.00 Please press the "Join" button to finish your transaction in PayPal.Your total today is: Price: $0.00 Please press the "Join" button to finish your transaction in PayPal.Choose Your Installment Plan?2 Installments ($592.50 per payment)4 Installments ($296.25 per payment)6 Installments ($197.50 per payment)12 Installments ($98.75 per payment)Your total today is: Price: $0.00 Please press the "Join" button to finish your transaction in PayPal.