Membership Application

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Membership Level:

Membership $1,000

Membership Plus $1,100

Membership Gold $1,250

If you are paying by credit card and would like your membership to automatically renew each year, please click on the box below. Your credit card will be charged one year from today for next year's membership. This auto renew feature can be cancelled at any time by logging into your account with us and changing this setting or contacting us at treasurer@impact100chicago.org and requesting that we do so for you.

The membership you have selected will automatically renew.

First Name: Last Name: Company: Company Match Program

My employer offers a matching gift program

Referred by Email: Home Phone: Home Address: City: State: Zip: -

Committee Participation

If you would like to participate on a grant review and/or a finanical review committee, please indicate your preferences below.

Grant Review

Financial Review

Preferred Regions

Each year we determine grant review and financial review committee locations based upon our membership preferences and the level of grant funds to be awarded. Please indicate which regions (you may select more than one) you would like to participate in. We will do our best to accomodate as many of our members as we can based upon these responses.

City

North Suburbs

Northwest Suburbs

West Suburbs

South Suburbs

Tax Letter

I would like tax letter emailed to me

Display name and city

Display my name and city on current membership list on main page

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