*Make checks payable to IMPACT 100 Men Inc. and mail to 335 East Linton Blvd. Suite 2219 Delray Beach, FL 33483

When contributing your membership fee to Impact 100 Men Inc., make a payment of $1500.00. All payments are due on or before July 1 in the year preceding the year the grant is awarded to be eligible to vote for the grant finalists.

Salutation

Name

First Name

Last Name

Mobile Phone

We prefer mobile phone.

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I would like to volunteer to be on a committee (optional)

Volunteer Professional Expertise

Do you or your family members own or operate a 501(c)(3) charitable organization?

Yes

If you or a family member own or operate a 501(c)(3) charitable organization, operating in Palm Beach County, please provide the following information below:

o Please provide the name of the 501 c3 charitable organization. o Please provide the relationship to you of the family member. Ie. (you, spouse, sibling, brother-in-law, etc.)

Do you serve on a committee or as an officer or director of any charitable organization?

Yes

Do you serve on a committee or as an officer or director of any charitable organization?

o Please provide the name of the 501 c3 charitable organization. o Please identify your most significant governing role in the organization? Ie. (committee name, secretary, director, etc.)

Do you belong to a charitable organization?

Yes

If you are a significant donor and/or a consistent volunteer with any 501(c)(3) charitable organization, operating in Palm Beach County, please provide the following information:

o Please the name of the 501 c3 charitable organization. o Describe your roll(s) in the organization. Ie. ( major donor, frequent volunteer, etc.)

Comments

Email Opt-Out:

Yes, I do not want to receive any emails.

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Impact 100 Men is a Grant Provider for Education, Personal and Social Services for Children.

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Impact 100 Men is a Grant Provider for Education, Personal and Social Services for Children.