STOCK GIFT VERIFICATION FORM
To be completed by the donor.
Donor's name
*
First Name
Last Name
I am contributing
*
(number of shares)
Shares of
*
(stock name)
My donation is in support of the following AOA programs: [Provide the percentage to each AOA program you wish to support with this donation]
Rows
Percentage
Unrestricted Support/Mission Critical Education
Council of Orthopaedic Residency Directors (CORD) Program and Academic Activities
Emerging Leaders Program
Leadership Development
Resident Leadership Activities
Own the Bone Program
American-British-Canadian Traveling Fellowship
Austrian-Swiss-German
Traveling Fellowship
Japanese Orthopaedic Association Traveling Fellowship
North American Traveling Fellowship
AOA Traveling Fellowship Programs
Carousel/Presidential Activities
TOTAL MUST EQUAL 100% (see calculation below)
Calculation of above percentages (MUST EQUAL 100)
If this gift of stock is a tribute gift and In Honor of someone, please include their name.
I can be reached at
*
Please enter a valid phone number.
Format: (000) 000-0000.
or email with any questions about my gift
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Verification signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Thank you
Submit
Should be Empty: