Geneva Centre for Autism Donation Form

Geneva Centre for Autism Stocks Donation Form
3 EASY STEPS TO INITIATE A TRANSFER:
1. Complete this online form
2. Send a copy of the PDF document found in the donation confirmation email to your broker.
3. Your broker can arrange for the electronic transfer of shares to the Geneva Centre for Autism Foundation account at BMO Nesbitt Burns: 658-09114-17
  
  Broker:
  Douglas M. Jones, CIM
  Vice President- Senior Investment Advisor, Portfolio Manager and Wealth Advisor
  BMO Nesbitt Burns Inc.
  1 First Canadian Place, 40th Floor, P.O. Box 150, Toronto, Ontario M5X 1H3 | Phone: 416-359-7667
  Direct cell: 416-522-9775
  Doug.Jones@nbpcd.com
  
  Transfer information:
  1 First Canadian Place
  P.O. BOX 150, 40th floor
  Toronto, ON M5X 1H3
  FINS#: T009
  CUID: NTDT
  DTC#: 5043
  EUROCLEAR#: 90098
  Mutual Fund Dealer/Rep code: 9185-KGC
Please be advised that the value of the donation receipt will be based on the closing price of the shares on the day the securities are received by the Foundation’s custodian, in accordance with our Board Policy. Charitable Registration # 86866 4640 RR0001. Geneva Centre for Autism Foundation respects your privacy and does not rent, sell or trade any donor information to third parties. All information relating to your contributions is held in the strictest confidence.
This form is to be completed by the donor or the donor’s agent and sent to the donor’s agent. For privacy reasons, shares are transferred anonymously from the broker, thus the information provided below enables us to issue a tax receipt to the donor.
Donor Information:
Title
Donor’s Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
E-mail*
example@example.com
Phone Number*

Area CodePhone Number
Share Information:
Security Description*
Number of Shares*
CUSIP#
Broker Information:
Broker Name
Broker’s Firm
Broker’s Phone

Area CodePhone Number
Broker’s Fax

Area CodePhone Number
Broker’s Email
example@example.com
Gift Designation:
Gift Designation*

GCA general foundationGroup ProgramsOther
Authorization:
Donor Signature

Clear
Date

MonthDayYear
Date
Additional Information
You may contact me in the future by email:*

YesNo
Corporate Donation:

This donation is on behalf of a company
Company Name:
Company Name
Anonymous:

I prefer to make this donation anonymously
Tribute Information
Type:
Name

First NameLast Name
Mail a letter?

Yes, mail a letter on my behalf
Recipient's Information
Recipient's Name

First NameLast Name
Recipient's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Recipient's Email
example@example.com
Recipient's Phone Number

Area CodePhone Number
Thank You!

Charitable registration #: 86866 4640 RR0001
Donation Date:

MonthDayYear
Date
Receipt Date:

MonthDayYear
Date
Gift Amount:
Eligible Amount:
Description of property donated:
Fair Market Value appraised by:
Address of appraiser:
Should be Empty:

Geneva Centre for Autism Stocks Donation Form

Donor Information:

Share Information:

Broker Information:

Gift Designation:

Authorization:

Additional Information

Tribute Information

Recipient's Information

Thank You!