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Stock Transmittal Form

Please complete the form below. Required fields marked with an asterisk *

Your Information

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Maiden Name

Answer required for "Maiden Name"

AQ Class Year*

Answer required for "AQ Class Year"

Email*

Answer required for "Email"

Phone*

Number Required

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

Zip/Postal*

Answer required for "Zip/Postal"

Broker Information

Broker Name*

Answer required for "Broker Name"

Broker Phone*

Number Required

Broker Email

Answer required for "Broker Email"

Stock Information

Name of Stock*

Answer required for "Name of Stock"

Number of Shares*

Answer required for "Number of Shares"

Type of Stock*

Answer required for "Type of Stock"

Intended Date of Transfer*

Answer required for "Intended Date of Transfer"

Gift Information

Designate my gift for:*

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AQ's Greatest Needs Scholarship

Financial Aid

Other:

Gift Recognition

My gift is in honor/memory of:

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Comments

Special instructions for processing gift:

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