Online Membership Form Please use this form to join Impact 100 Greater Indianapolis. Go to https://www.impact100indy.org/join/onlinedonation/ if you wish to make a donation in lieu of joining. Contact us at impact100indy@gmail.com if you have any questions.Name* First Name Last Name I request that Impact 100 NOT use my name on their website and/or social media as an Impact 100 member or donor. Email* Mobile Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Employer Occupation Membership Level: Full or Shared100% of your Membership Donation goes into the Grant Pool and is given back to our community in the form of Grants each year. Impact 100 Greater Indianapolis is an IRS recognized 501(C)(3) charitable organization. Your donation is tax deductible to the full extent permitted by law.HiddenFull Membership--HIDDEN NO LONGER USEDIf you wish to be a full member, please CLICK IN THE BOX BELOW TO SELECT THE LEVEL OF MEMBERSHIP DONATION YOU WISH TO MAKE. Please consider joining our Friends and Supporter members who give an additional amount to help cover our Administrative costs, or at least adding $35 to help pay our credit card fees.-Full MembershipMember and Friend: $1,250 donation ($1,000 to grant pool and $250 to help pay administrative costs)Member and Supporter: $1,100 donation ($1,000 to grant pool and $100 to help pay administrative costs)Member plus charge card fees: $1030 ($1000 to grant pool and $30 to help cover credit card fees)Member: $1,000 donationFull MembershipIf you wish to be a FULL MEMBER, please SELECT THE LEVEL OF FULL MEMBERSHIP DONATION YOU WISH TO MAKE. Please consider joining our members who give an additional amount to help cover our operating costs, or at least adding $50 to help pay the credit card fees. (NOTE: If you wish to make a partial payment of your membership donation, please skip to Partial Payment.) Member and Friend: $1,250 donation ($1,000 to grant pool and $250 to help pay administrative costs) Member and Supporter: $1,100 donation ($1,000 to grant pool and $100 to help pay administrative costs) Member plus charge card fees: $1,050 ($1,000 to grant pool and $50 to help cover credit card fees) Member: $1,000 donation Partial Payment for a Full Membership:We allow a partial payment of your Membership of at least $250 with the remainder to be paid before December 31. Please enter the amount of your partial payment here, and use the Notes field to tell us when you will pay the remaining amount. You may break the remainder into one or two payments, and ask to be invoiced on October 1 and/or December 1. Remember, the full amount of your Membership must be paid by December 31. You will not receive a tax acknowledgement until the full amount is received. HiddenShared Membership--HIDDEN NO LONGER USEDIf you wish to be a part of a Shared Membership, CLICK IN THE BOX BELOW TO SELECT THE LEVEL OF SHARED MEMBERSHIP DONATION YOU WISH TO MAKE. If you know the names of one or more of the women with which you wish to share your membership, please enter their name(s) in the Notes field. Otherwise, we will group you with other women who have requested a Shared Membership.Shared MembershipOne-Half Shared Member: $500 to grant poolOne-Third Shared Member: $334 to grant poolOne-Quarter Shared Membership: $250 to grant poolShared Membership--LevelIf you wish to be a part of a SHARED MEMBERSHIP, please select the LEVEL OF SHARED MEMBERSHIP DONATION you wish to make below, then consider joining our members who give an additional amount to help cover our operating costs in the next section. We suggest you at least give an additional 10% to help cover credit card administration and fees. If you know the names of one or more of the women with which you wish to share your membership, please enter their name(s) in the Notes field. Otherwise, we will group you with other women who have requested a Shared Membership. One-Half Shared Member: $500 to grant pool One-Third Shared Member: $334 to grant pool One-Quarter Shared Membership: $250 to grant pool PriceOur Members often contribute extra to help pay operating costs and/or credit card fees. If you would like to help with these costs, please enter the amount you would like to donate in the field below. Additional Donation to the Scholarship FundSome of our members make additional donations to our Scholarship Fund. These donations increase the Grant Pool AND pay the membership fees for a woman studying philanthropy or involved in an area nonprofit who would not be able to participate in Impact 100 without these scholarship funds. Enter the amount you would like to donate in the field below. Member ParticipationMembers may choose to play an active role in the organization by serving on a Board Committee.I am interested in learning more about serving on the following Board Committee(s): Membership Fundraising Marketing/Communications Annual Celebration Scholarship Let's discuss where my skills and experience would be needed. NotesPlease use the Notes field to give us more information regarding your Membership and/or Donation choices.Total $0.00 Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name CAPTCHA Δ
