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* Mandatory fields
*First name
*Last name
Cell Phone
 Options ($USD)
* Includes Gift Membership(s) - specify names below
** Does not include Membership
Specify name on credit card
 Payment Frequency
Annual Payment Agreement
For Annual Payments, please type your initials

Note: may be cancelled at any time before next payment date by emailing treasurer@impact100westchester.org
Membership Type
Clear selection
For Memberships and Gift Memberships, specify whether this is a renewal or new membership
Gift Membership
For Gift Memberships, specify each recipient's name, email and cell phone
Honor/Memory Of Donation
For Honor/Memory Of Donations, specify name and email for acknowledgement (other than donor)

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