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Registration Form

To join IMPACTjax, please complete the registration form below. You will receive an invoice via email by the end of the week.

Once your payment has been received, you will receive a welcome email and your IMPACTjax membership will be activated. Thank you very much!

Company Information

Full Name:*

Company Name:*

Address:

City:

State:

Zip:

Chamber of Commerce member?:*

Yes
No
Not Sure

Position:*

Meeting Times That Work Best For Your Schedule:*

Mailing Address

Address:*

City:*

State:*

Zip:*

Billing Address

Address:*

City:*

State:*

Zip:*

Contact Information

Preferred Phone Number:*

Fax:

Email Address:*

Preferred Method of Contact:*

Phone
Fax
Email

Personal Interview

How Long Have You Lived In Jacksonville?:

How Did You Hear About IMPACTjax?:

Areas of Interest (check all that apply):

Volunteer Work

Personal development/ Social Opportunities

Professional development/ Networking

Government/ Politics

Improving Jacksonville

The Chamber of Commerce

Cultural development/ Education

IMPACTjax leadership

Chamber leadership

Future Goals (check all that apply):

Elected office

Leadership in area non-profit organizations

Growth in current company

Business leadership position

Entrepreneurship

Move away from Jacksonville

Other

Education:

Some High School

High school diploma

Some College

Associates Degree

Bachelor's degree

Graduate degree

Organization Affiliation (check all organizations that you are a member of):

JCCI/JCCI Forward

HandsOn Jacksonville

Rotoract

Jaycees/Jr. Chamber

Leadership Jacksonville/Leadership Florida

Social Spirits

Up and Cummers

Opus

University Club Young Executives

Thursday Nite Drinking Club

Professional Organization

Young Democrats

Young Republicans

Other

Please list any of the above organizations about which you would like more information:

Statistical Information

Birth Date:*

Ethnicity:

Household Income:

Marital Status:

Number of Children:

Membership Fees

Select one:*

Chamber of Commerce member $50
Non-Chamber of Commerce member $70