Be grateful for whoever comes, because each has been sent as a guide from beyond. Rumi
Idea Transcript
Securities Transfer Form
To be completed by Donor: Name of Donor:
Daytime Telephone:
Address of Donor: Brokerage Firm: Address of Delivering Institution: Account # at Delivering Institution: Name of Security:
# of Shares Transferred:
Approx. Value of Each Share: $
Approx. Total Amount of Donation: $
Date of Transfer to the Pan Am Clinic Foundation Account: This letter will serve as your authorization to release the securities noted above to the account of Pan Am Clinic Foundation. I understand that I will receive a Gift-in-Kind tax receipt from the Pan Am Clinic Foundation for the transfer to the Pan Am Clinic Foundation account at Capital Campaign Account Number 783-28820-18, Royal Bank of Canada, these securities have been donated to the Pan Am Clinic Foundation without restriction and can be sold by the Pan Am Clinic Foundation at any time. Signature of Donor:
Date:
Please advise the Pan Am Clinic Foundation of your donation: Jeff Leiter Executive Director Pan Am Clinic Foundation 75 Poseidon Bay Winnipeg Manitoba R3M 3E4 Receiving Institution Information RBC Dominion Securities Att: Mr. Al McLaughlin 8th Floor One Lombard Place Winnipeg Manitoba R3B 0Y2