GIFT OF STOCK FORM
Please complete the information below to notify the UP Land Conservancy of your gift and to ensure it is processed and acknowledged accurately. Please email the form to uplc@uplandconservancy.org when completed if printed.
Securities Information
Name & Type of Securities (e.g.: Dell common stock) *
Your answer
Security Symbol *
Your answer
Number of Shares *
Your answer
Transfer Date *
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Donor Name (Individual, Household, Corporation, Foundation) *
Your answer
Donor Street Address *
Your answer
Donor City/State/Zip *
Your answer
Donor Telephone/ Email Address (to be used only if a question arises in the donation process) *
Your answer
Broker Name *
Your answer
Broker Company/City/State *
Your answer
Broker Contact/Telephone Number *
Your answer
By checking the box below and entering my initials, I am indicating that the information provided above is complete and accurate to the best of my knowledge. *
Required
Initial here *
Your answer
Date Signed *
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Donor 2: By checking the box below and entering my initials, I am indicating that the information provided above is complete and accurate to the best of my knowledge.
Donor 2: Initial Here
Your answer
Donor 2 Date Signed
MM
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DD
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YYYY
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