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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:




_______________________________          _______________________________
Signature                                                                  Account #


_______________________________          _______________________________
Name (Please Print)                                                 Phone



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


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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