Impact100 Westchester - Credit Card Donations

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* Mandatory fields

*First name

*Last name

*Email

Cell Phone

*Options ($USD)

Donation $ only (EXCLUDES Membership)

Membership $1,150.00 (USD)

Membership + Donation $1,250.00 (USD)

Membership + Donation $1,500.00 (USD)

Membership + Donation $2,000.00 (USD)

2 Memberships $2,300.00 (USD)

3 Memberships $3,450.00 (USD)

*Cardholder

Name on credit card

*Membership Type

New Membership

Renewal

If Gift Membership:

Name, email and cell for each recipient of Gift Membership

If Honor/Memory of Donation:

Name and email for Honoree acknowledgement

If Corporate Matching Gift:

Name of Company and name of Employee if different than name of Member

APPLY FO