Impact 100 Men of Palm Beach County

Membership Registration

     
 
 
 
 
Company 
Salutation 
Nick Name 
First Name 
Last Name 
Email 
Mobile 
Street 
City 
State/Province 
Zip 
Referral 
Birthday 
Volunteer Professional Expertise
 
Do you or your family members own or operate a 501(c)(3) charitable organization?

Yes
No
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
No
If you are currently on a governing committee or are an officer or director of any 501(c)(3) charitable organization operating in Palm Beach County, please provide the following information:
o Please provide the name of the 501 c3 charitable organization.
o Please identify your most significant governing role in the organization? Ie. (committee member, secretary, director, etc.)
 
Do you belong to a charitable organization?

Yes
No
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 provide the name of the 501 c3 charitable organization.
o Describe your role(s) in the organization. Ie. ( major donor, frequent volunteer, etc.)
 
 
Have you changed your address or primary phone number?

Yes
No
If you changed your address since you last joined Impact 100 Men, please enter the change below:
 

 

Impact 100 Men Inc., a Florida not-for-profit corporation, is registered with the Florida Department of Agriculture and Consumer Services under registration #CH62772.  It is a Section 501(c)(3) charitable organization under the Internal Revenue Code.  A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION OF IMPACT 100 MEN INC. MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY VISITING THEIR WEBSITE (WWW.FDACS.GOV) OR BY CALLING THEIR TOLL-FREE NUMBER (1-800-435-7352) WITHIN THE STATE. REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL, OR RECOMMENDATION BY THE STATE.