Stock Gifts Notification Form

First Name

MI

Last Name

Email

Address Line 1

Address Line 2

City

Country

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State

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Provinces

Please select... Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

State/Province

Postal Code

Phone

Type of stock

What is the name of the company, stock fund, etc.?

Number of shares

Approximate Transfer Date

Your brokerage firm

Ex: Charles Schwab, Merrill Lynch

Is there anything else we should know?

Questions? Contact Erika Rain Wilhite, NCCJ's development director, at ewilhite@nccjtriad.org or 336-272-0359 x 150.