Letter Of Direction To Gift Securities Form

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Letter of Direction to Gift Securities
Name of Your Broker
Broker’s Title
Broker Company Name
Broker Address
City, Province, Postal Code
Broker’s Phone / Broker’s Fax
Broker’s Email
Date
Dear Broker:
This letter will authorize you to transfer securities as a donation to the Queensway Carleton Hospital
Foundation (Charitable Business #13725 3571 RR0001). To my knowledge, these shares are not subject to
restrictions on their sale or disposition and I am not aware of any material undisclosed information concerning
the shares.
Please transfer the shares…
From my account #
To RBC Dominion Securities account # 508-01043-1-7 (CUID # DOMA / FINS # T002 / DTC # 5002)
On this date
Securities to be donated
Company name or description
Stock symbol or CUSIP #
Number of shares
or shares to value approximately $
My current address and contact information is…
Name
Address
City
Prov
Postal Code
Home Phone
Work Phone
Cell Phone
Email
Fax
_____________________________________
Signature of Donor
Prior to making the transfer, please FAX a completed copy of this form to:
David Houghton, Client Transfer Services, RBC Dominion Securities, FAX 613-721-4680
th
303 Moodie Drive, 5
Floor, Ottawa / Phone 613-721-8237 / Email
and to
Judith Scott, Queensway Carleton Hospital Foundation, FAX 613-721-4755

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