CORPORATE
DONOR ADVISED FUND APPLICATION
Donor Information
| Corporation |
|
| |
|
| ____________________________________________________ |
________________________ |
| Name |
Telephone |
| ____________________________________________________ |
________________________ |
| Address |
Fax |
| ____________________________________________________ |
________________________ |
| City/State/Zip |
E-mail |
| ____________________________________________________ |
________________________ |
| EI Number |
Contact (Name) |
| |
|
| Advisor |
|
| ____________________________________________________ |
________________________ |
| Name |
Telephone |
| ____________________________________________________ |
________________________ |
| Address |
Fax |
| ____________________________________________________ |
________________________ |
| City/State/Zip |
E-mail |
| |
|
| Advisor |
|
| ____________________________________________________ |
________________________ |
| Name |
Telephone |
| ____________________________________________________ |
_________________________ |
| Address |
Fax |
| ____________________________________________________ |
_________________________ |
| City/State/Zip |
E-mail |
Unless the Donor notifies Southern Tier
West Development Foundation otherwise in writing, each Advisor
shall have the full, equal and independent privilege to recommend
grant distributions, but shall not have the right to designate
Advisors. To designate additional and/or other Advisors and to
recommend the final disposition of the fund, please complete the
Program Options form.
INITIAL CONTRIBUTION ($10,000 minimum)
Cash Amount
Securities of Publicly Traded Companies
Other Securities - Contact Southern
Tier West Development Foundation to discuss
contributions of restricted securities and securities of privately
held
companies.
Mutual Funds - Contact Southern
Tier West Development Foundation for transmittal instructions.
Other Assets -contact Southern Tier
West Development Foundation
AUTHORIZATION TO LIST NAME OF FUND IN ANNUAL REPORT
We authorize Southern Tier West Development Foundation to list
the name of this Fund in its Annual Report
Please initial:_______________ Please initial:____________________
HOW DID YOU LEARN ABOUT SOUTHERN TIER WEST DEVELOPMENT FOUNDATION?
Referred by:_________________________________________________________
Radio Advertisement:_________________________________________________
Print Advertisement:_________________________________________________
Other:______________________________________________________________
