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Inland Foundation
200 Kennedy Memorial Drive
Waterville, ME 04901
(207) 861-3377

Letter of Authorization To Broker

 

Date: _______________________________

 

Broker’s Name: _______________________________

Company: ___________________________________

Address: ____________________________________

____________________________________

Phone: _______________________________

 

Dear _____________________ :

Please transfer to the Inland Foundation the following securities:

 

______________________________________________________________

 

The Inland Foundation prefers that the securities be electronically transferred to the Foundation’s account at A.G. Edwards in Waterville, ME.

Feel free to contact Marc A. Pitman, Director of the Inland Foundation, at (207) 861-3377.

 

Firm: A.G. Edwards
DTC # 0-201
For the benefit of Inland Foundation Account #xxxxxxxx
Inland Foundation Federal ID # xx-xxxxxxx
Contact: Rxxxr Kxxxxx, 222 Kennedy Memorial Drive, Waterville, ME 04901

 

This gift is for the benefit of the following department, program, fund, or project:

______________________________________________________________

______________________________________________________________
Sincerely,

 

_______________________________          _______________________________
Signature                                                                  Account #

 

_______________________________          _______________________________
Name (Please Print)                                                 Phone

 

 

cc: Inland Foundation (mail or fax: 207-861-3039)

Downloads

Broker Authorization Form (pdf)

Here is a PDF of a simple broker authorization form that you can use in making your own.

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