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InerG Impact Membership Interest Form
Please read prior to completing the form:
Thank you for taking the time to tour InerG Impact! We're very grateful that you are interested in becoming a part of our Community centered on impact and change for Anderson, Indiana. After our Grand Opening, we received a high influx of inquiries via social media, email, and phone.
You'll hear back from us within one to two weeks!
Our staff is working very hard to respond to each of you individually. W
e humbly ask that you remain patient as we diligently follow our processes to ensure our mission to create impact, extract potential, and serve
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Date
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Have you attended an in-person tour of our facility?
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Yes
No (Please schedule a tour before completing this membership interest form.)
Last Name
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Your answer
First Name
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Your answer
Business/Organization Name
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Your answer
Home Address Line 1
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Your answer
Home Address Line 2
Your answer
City, State/ Zip Code
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Your answer
Phone Number
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Your answer
Email
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Your answer
Emergency Contact (First and Last Name)
Your answer
Emergency Contact Number
Your answer
Emergency Contact Relationship
Your answer
Which best describes the co-working membership you desire to have at InerG Impact?
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Virtual Membership ($25 per month)
Clergy Access ($30 per month)
Community Membership ($50 per month)
Corporate Access (prices vary)
Business/Individual seeking private office space (Starting at $200/Month)
How many employees does your business have?
(Please note: Businesses with more than four employees are advised to have designated office space.)
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1-10
20-50
50-100
N/A
Does your business have Liability Insurance?
(You must provide proof of insurance if private office membership is desired.)
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Yes
No
In the process of getting insurance.
N/A
One of InerG Impact's core values is to provide a social impact within the Anderson community. With that in mind, we desire for every member to assist us in contributing to upholding this value. Which of the following goal(s) are most important to your organization as it relates to building a sustainable community in Anderson? Select all that apply.
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Combat poverty in this community.
End hunger in this community.
Provide education for well-being in the community.
Provide quality education in this community.
Provide decent work and economic growth in this community.
Develop innovative programs in this community.
Reduce inequality in this community.
Create a sustainable city and community.
Other. Explain below.
Required
If other was selected above, what is your business' goal in supporting the Anderson community?
Your answer
Where do you see your business in 5 years? Are you looking to expand or hire more employees?
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Your answer
If interested in private office space, what term works best for your business?
Monthly Commitment
12 Month Lease
N/A: only interested in co-working space.
Clear selection
Estimated date of starting membership/leasing space?
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MM
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DD
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YYYY
All co-workers will have access to shared bathrooms, wifi, kitchenette (sink, coffee bar, microwave, etc.), paper shredding, eating area, and shared parking. What other features are you interested in?
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Shared printer/scanner/fax
3-D printing
Conference Room
Kitchen/The Gathering Place Venue
Fitness Center
Gymnasium
Other:
Required
How did you hear about InerG Impact?
Internet search
Drive-by
Word of Mouth
Social Media
Other:
Clear selection
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