Please mail this form and payment to:

IMPACT, Inc.
Attn.Membership
P.O.Box 363
Marietta, GA. 30061

First Name: ______________________________________

Last Name: ______________________________________

Address: ________________________________________

Phone Number: __________________________________

E-Mail: _________________________________________

Type of Membership: (Circle one)

Individual ($ 10.00 per year)

Senior ($ 5.00 per year)

Neighborhood ($ 50.00 per year) Less than 100 homes

Neighborhood ($ 100.00 per year) More than 100 homes

Area of Interest: __________________________________

Comments: ______________________________________