CINXE.COM

<html> <head><script type="text/javascript" src="https://web-static.archive.org/_static/js/bundle-playback.js?v=7YQSqjSh" charset="utf-8"></script> <script type="text/javascript" src="https://web-static.archive.org/_static/js/wombat.js?v=txqj7nKC" charset="utf-8"></script> <script>window.RufflePlayer=window.RufflePlayer||{};window.RufflePlayer.config={"autoplay":"on","unmuteOverlay":"hidden"};</script> <script type="text/javascript" src="https://web-static.archive.org/_static/js/ruffle/ruffle.js"></script> <script type="text/javascript"> __wm.init("https://web.archive.org/web"); __wm.wombat("https://www.stockgifts.duke.edu/","20160213143634","https://web.archive.org/","web","https://web-static.archive.org/_static/", "1455374194"); </script> <link rel="stylesheet" type="text/css" href="https://web-static.archive.org/_static/css/banner-styles.css?v=p7PEIJWi" /> <link rel="stylesheet" type="text/css" href="https://web-static.archive.org/_static/css/iconochive.css?v=3PDvdIFv" />  <title>Make a Stock/Security Gift to Duke</title> <script language="Javascript" src="/web/20160213143634js_/https://www.stockgifts.duke.edu/include/core.js"></script> <script language="Javascript" src="/web/20160213143634js_/https://www.stockgifts.duke.edu/include/ValidationFunctions.js"></script> <script language="Javascript"> ie4 = ((navigator.appName == "Microsoft Internet Explorer") && (parseInt(navigator.appVersion) >= 4 )); ns5 = ((navigator.appName == "Netscape") && (parseInt(navigator.appVersion) >= 5 )); </script> <script language="Javascript"> function opencalendar(frmfld, frmname) { var newWind=window.open('calendar.cfm?frmfld=' + frmfld + '&frmname=' +frmname,'rsrvcalscreen','width=325,height=230,left=150,top=150'); if (newWind.opener == null) { newWind.focus(); } } </script> <script language="Javascript"> function update_disabled(obj, yourform, enabled) { if (document.getElementById) { for (var i = 0; i < yourform.elements.length; i++) { if (yourform.elements[i].id.indexOf('_dis'+index) != -1) { yourform.elements[i].disabled = (!enabled); } } } } </script> <style type="text/css"> BODY { font-family: sans-serif; font-size: 13px; } TD { font-family: sans-serif; font-size: 13px; } FONT.small { font-family: sans-serif; font-size: 11px; } .heading1 { font-size: 16px; font-weight: bold; } TD.highlight { background-color: ffffcc; } TD.colheader { background-color: 000066; color: white; align: center; font-weight: bold; padding-left: 10px; padding-right: 10px; } INPUT.secnamefield { width: 300px; } INPUT.secnumsharesfield { width: 100px; } INPUT.secvalsharesfield { width: 100px; } .disabledTextArea { background-color: cccccc; } .enabledTextArea { background-color: ffffff; } </style> <script language="Javascript" src="/web/20160213143634js_/https://www.stockgifts.duke.edu/validate.js"></script> </head> <body background="/web/20160213143634im_/https://www.stockgifts.duke.edu/gift_background.gif" leftmargin="0" marginwidth="0"> <form name="frmStockGift" method="POST" action="stock_gift_process.cfm" name="frmStockGift" onsubmit="return validateForm('');"> <table cellpadding="0" cellspacing="0" border="0" width="100%"> <tr> <td width="50"><img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/spacer.gif" width="50" border="0" height="1"></td> <td width="100%"> <table cellpadding="0" cellspacing="1" border="0"> <tr> <td> <font style="font-size: 50px; font-family: serif; font-variant: small-caps; color: 003366;">Duke University</font> </td> </tr><tr> <td bgcolor="cc9933"><img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/spacer.gif" width="1" height="2" border="0"></td> </tr><tr> <td> <font style="font-size: 42px; font-family: serif; color: 003366;">Make a Stock Gift</font> </td> </tr> </table> <p> <table align="right"><tr><td>  <script language="JavaScript" type="text/javascript" src="//web.archive.org/web/20160213143634js_/https://smarticon.geotrust.com/si.js"></script>  </td></tr></table> For more information about giving to Duke, visit the <a href="https://web.archive.org/web/20160213143634/http://www.development.duke.edu/" target="_blank">Duke University Development</a> and the <a href="https://web.archive.org/web/20160213143634/http://www.giftrecords.duke.edu/" target="_blank">Alumni & Development Records</a> web sites. For specific questions contact the Alumni & Development Records Office via e-mail at <a href="https://web.archive.org/web/20160213143634/mailto:stockgifts@duke.edu">stockgifts@duke.edu</a> or via telephone at (919) 684-2338. <p> <b>This form allows you to declare your intention to make a stock gift so that we may credit your gift appropriately. You must contact your broker to initiate the actual transaction.</b> <p> Upon completion of this form, you will receive a confirmation email, as well as transfer instructions and applicable forms that will assist you in completing your gift to Duke. <p> <noscript> <table width="80%" align="center" border="0" cellpadding="4" cellspacing="0" bgcolor="ff9999"><tr><td> <font size="4"><b> Warning: This form requires that you be using a javascript-enabled web browser. You do not appear to have javascript enabled. Please enable javascript and then reload this page. </b></font> </td></tr></table> </noscript> <table width="100%" border="0" cellspacing="0" cellpadding="1"> <tr> <td width="100%"><span class="heading1">Start Here</span></td> </tr> <tr> <td bgcolor="#ffcc33"><img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/spacer.gif" width="1" height="1"></td> </tr> </table> Are you the donor or the broker?<br>     <input type="radio" name="RESPONDENT" value="DONOR" checked>Donor      <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required.gif" alt="Required Field" width="9" height="14" hspace="3"> indicates a required field if you are the donor.<br>     <input type="radio" name="RESPONDENT" value="BROKER">Broker     <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required_blue.gif" alt="Required Field" width="9" height="14" hspace="3"> indicates a required field if you are the broker.<br> <p> <script language="Javascript"> function copyEmail(fld) { fld.value = Trim(fld.value); if (document.frmStockGift.RESPONDENT[0].checked) { document.frmStockGift.DONOR_EMAIL.value = fld.value; } } </script> <table border="0" cellpadding="3" cellspacing="0"> <tr> <td align="right" class="highlight">Your email address:</td> <td class="highlight"><input style="width: 200px;" name="EMAIL_OF_SUBMITTER" type="text" onfocus="select();" onfocus="select();" onblur="copyEmail(this);"> <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required.gif" alt="Required Field" width="9" height="14" hspace="3"> <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required_blue.gif" alt="Required Field" width="9" height="14" hspace="3"></td> </tr> <tr> <td align="right"><img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/spacer.gif" width="200" height="1" border="0"></td> <td width="100%"></td> </tr> </table> <p> <table width="100%" border="0" cellspacing="0" cellpadding="1"> <tr> <td width="100%"><span class="heading1">Donor Information</span></td> </tr> <tr> <td bgcolor="#ffcc33"><img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/spacer.gif" width="1" height="1"></td> </tr> </table> Please enter information about the donor in the following fields:<br> <br> <input type="CHECKBOX" name="GIVEN_BEFORE" value="YES"> Check here if the donor has previously given gifts to Duke. <p> <table border="0" cellpadding="3" cellspacing="0"> <tr> <td align="right" class="highlight">Donor's First Name:</td> <td class="highlight"><input name="FIRST_NAME" type="text" onfocus="select();"> <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required.gif" alt="Required Field" width="9" height="14" hspace="3"> <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required_blue.gif" alt="Required Field" width="9" height="14" hspace="3"></td> </tr> <tr> <td align="right" class="highlight">Donor's Middle Name:</td> <td class="highlight"><input name="MIDDLE_NAME" type="text" onfocus="select();"></td> </tr> <tr> <td align="right" class="highlight">Donor's Last Name:</td> <td class="highlight"><input name="LAST_NAME" type="text" onfocus="select();"> <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required.gif" alt="Required Field" width="9" height="14" hspace="3"> <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required_blue.gif" alt="Required Field" width="9" height="14" hspace="3"></td> </tr> <tr> <td align="right" class="highlight">Home Address Line 1:</td> <td class="highlight"><input name="ADDRESS1" type="text" onfocus="select();" size="35"> <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required.gif" alt="Required Field" width="9" height="14" hspace="3"></td> </tr> <tr> <td align="right" class="highlight">Home Address Line 2:</td> <td class="highlight"><input name="ADDRESS2" type="text" onfocus="select();" size="35"></td> </tr> <tr> <td align="right" class="highlight">City:</td> <td class="highlight"><input name="CITY" type="text" onfocus="select();"> <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required.gif" alt="Required Field" width="9" height="14" hspace="3"></td> </tr> <tr> <td align="right" class="highlight" valign="top">State:</td> <td class="highlight"> <select name="STATE" id="STATE" size="1"> <option value=""></option> <option value="AL">AL - Alabama </option> <option value="AK">AK - Alaska </option> <option value="AS">AS - American Samoa </option> <option value="AZ">AZ - Arizona </option> <option value="AR">AR - Arkansas </option> <option value="CA">CA - California </option> <option value="CO">CO - Colorado </option> <option value="CT">CT - Connecticut </option> <option value="DE">DE - Delaware </option> <option value="DC">DC - District of Columbia </option> <option value="FL">FL - Florida </option> <option value="GA">GA - Georgia </option> <option value="GU">GU - Guam </option> <option value="HI">HI - Hawaii </option> <option value="ID">ID - Idaho </option> <option value="IL">IL - Illinois </option> <option value="IN">IN - Indiana </option> <option value="IA">IA - Iowa </option> <option value="KS">KS - Kansas </option> <option value="KY">KY - Kentucky </option> <option value="LA">LA - Louisiana </option> <option value="ME">ME - Maine </option> <option value="MD">MD - Maryland </option> <option value="MA">MA - Massachusetts </option> <option value="MI">MI - Michigan </option> <option value="AP">AP - Military APO </option> <option value="AA">AA - Military APO </option> <option value="AE">AE - Military APO </option> <option value="MN">MN - Minnesota </option> <option value="MS">MS - Mississippi </option> <option value="MO">MO - Missouri </option> <option value="MT">MT - Montana </option> <option value="NE">NE - Nebraska </option> <option value="NV">NV - Nevada </option> <option value="NH">NH - New Hampshire </option> <option value="NJ">NJ - New Jersey </option> <option value="NM">NM - New Mexico </option> <option value="NY">NY - New York </option> <option value="NC">NC - North Carolina </option> <option value="ND">ND - North Dakota </option> <option value="MP">MP - Northern Mariana Isl </option> <option value="OH">OH - Ohio </option> <option value="OK">OK - Oklahoma </option> <option value="OR">OR - Oregon </option> <option value="PA">PA - Pennsylvania </option> <option value="PR">PR - Puerto Rico </option> <option value="RI">RI - Rhode Island </option> <option value="SC">SC - South Carolina </option> <option value="SD">SD - South Dakota </option> <option value="TN">TN - Tennessee </option> <option value="TX">TX - Texas </option> <option value="UT">UT - Utah </option> <option value="VT">VT - Vermont </option> <option value="VI">VI - Virgin Islands </option> <option value="VA">VA - Virginia </option> <option value="WA">WA - Washington </option> <option value="WV">WV - West Virginia </option> <option value="WI">WI - Wisconsin </option> <option value="WY">WY - Wyoming </option> </select> <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required.gif" alt="Required Field" width="9" height="14" hspace="3"> if a United States address.<br> Other: <input name="STATE_OTHER" type="text" onfocus="select();"> </td> </tr> <tr> <td align="right" class="highlight" valign="top">Country:</td> <td class="highlight"> <select name="COUNTRY" id="COUNTRY" size="1"> <option value=""></option> <option value="AF">AF - Afghanistan </option> <option value="AL">AL - Albania </option> <option value="DZ">DZ - Algeria </option> <option value="VI">VI - Amer.Virgin Is. </option> <option value="AD">AD - Andorra </option> <option value="AO">AO - Angola </option> <option value="AI">AI - Anguilla </option> <option value="AQ">AQ - Antarctica </option> <option value="AG">AG - Antigua/Barbuda </option> <option value="AR">AR - Argentina </option> <option value="AM">AM - Armenia </option> <option value="AW">AW - Aruba </option> <option value="AU">AU - Australia </option> <option value="AT">AT - Austria </option> <option value="AZ">AZ - Azerbaijan </option> <option value="BS">BS - Bahamas </option> <option value="BH">BH - Bahrain </option> <option value="BD">BD - Bangladesh </option> <option value="BB">BB - Barbados </option> <option value="BY">BY - Belarus </option> <option value="BE">BE - Belgium </option> <option value="BZ">BZ - Belize </option> <option value="BJ">BJ - Benin </option> <option value="BM">BM - Bermuda </option> <option value="BT">BT - Bhutan </option> <option value="BO">BO - Bolivia </option> <option value="BQ">BQ - Bonaire, Saba </option> <option value="BA">BA - Bosnia-Herz. </option> <option value="BW">BW - Botswana </option> <option value="BV">BV - Bouvet Islands </option> <option value="BR">BR - Brazil </option> <option value="IO">IO - Brit.Ind.Oc.Ter </option> <option value="VG">VG - Brit.Virgin Is. </option> <option value="BN">BN - Brunei Daruss. </option> <option value="BG">BG - Bulgaria </option> <option value="BF">BF - Burkina Faso </option> <option value="MM">MM - Burma </option> <option value="BI">BI - Burundi </option> <option value="KH">KH - Cambodia </option> <option value="CM">CM - Cameroon </option> <option value="CA">CA - Canada </option> <option value="CV">CV - Cape Verde </option> <option value="CF">CF - CAR </option> <option value="KY">KY - Cayman Islands </option> <option value="TD">TD - Chad </option> <option value="CL">CL - Chile </option> <option value="CN">CN - China </option> <option value="CX">CX - Christmas Islnd </option> <option value="CC">CC - Coconut Islands </option> <option value="CO">CO - Colombia </option> <option value="KM">KM - Comoros </option> <option value="CK">CK - Cook Islands </option> <option value="CR">CR - Costa Rica </option> <option value="CI">CI - Cote d'Ivoire </option> <option value="HR">HR - Croatia </option> <option value="CU">CU - Cuba </option> <option value="CW">CW - Cura鈹溌篴o </option> <option value="CY">CY - Cyprus </option> <option value="CZ">CZ - Czech Republic </option> <option value="CD">CD - Dem. Rep. Congo </option> <option value="DK">DK - Denmark </option> <option value="DJ">DJ - Djibouti </option> <option value="DM">DM - Dominica </option> <option value="DO">DO - Dominican Rep. </option> <option value="AN">AN - Dutch Antilles </option> <option value="TL">TL - East Timor </option> <option value="TP">TP - East Timor </option> <option value="EC">EC - Ecuador </option> <option value="EG">EG - Egypt </option> <option value="SV">SV - El Salvador </option> <option value="GQ">GQ - Equatorial Guin </option> <option value="ER">ER - Eritrea </option> <option value="EE">EE - Estonia </option> <option value="ET">ET - Ethiopia </option> <option value="FK">FK - Falkland Islnds </option> <option value="FO">FO - Faroe Islands </option> <option value="FJ">FJ - Fiji </option> <option value="FI">FI - Finland </option> <option value="FR">FR - France </option> <option value="PF">PF - Frenc.Polynesia </option> <option value="GF">GF - French Guayana </option> <option value="TF">TF - French S.Territ </option> <option value="GA">GA - Gabon </option> <option value="GM">GM - Gambia </option> <option value="GE">GE - Georgia </option> <option value="DE">DE - Germany </option> <option value="GH">GH - Ghana </option> <option value="GI">GI - Gibraltar </option> <option value="GR">GR - Greece </option> <option value="GL">GL - Greenland </option> <option value="GD">GD - Grenada </option> <option value="GP">GP - Guadeloupe </option> <option value="GU">GU - Guam </option> <option value="GT">GT - Guatemala </option> <option value="GG">GG - Guernsey </option> <option value="GN">GN - Guinea </option> <option value="GW">GW - Guinea-Bissau </option> <option value="GY">GY - Guyana </option> <option value="HT">HT - Haiti </option> <option value="HM">HM - Heard/McDon.Isl </option> <option value="HN">HN - Honduras </option> <option value="HK">HK - Hong Kong </option> <option value="HU">HU - Hungary </option> <option value="IS">IS - Iceland </option> <option value="IN">IN - India </option> <option value="ID">ID - Indonesia </option> <option value="IR">IR - Iran </option> <option value="IQ">IQ - Iraq </option> <option value="IE">IE - Ireland </option> <option value="IM">IM - Isle of Man </option> <option value="IL">IL - Israel </option> <option value="IT">IT - Italy </option> <option value="JM">JM - Jamaica </option> <option value="JP">JP - Japan </option> <option value="JE">JE - Jersey </option> <option value="JO">JO - Jordan </option> <option value="KZ">KZ - Kazakhstan </option> <option value="KE">KE - Kenya </option> <option value="KI">KI - Kiribati </option> <option value="XK">XK - Kosovo </option> <option value="KW">KW - Kuwait </option> <option value="KG">KG - Kyrgyzstan </option> <option value="LA">LA - Laos </option> <option value="LV">LV - Latvia </option> <option value="LB">LB - Lebanon </option> <option value="LS">LS - Lesotho </option> <option value="LR">LR - Liberia </option> <option value="LY">LY - Libya </option> <option value="LI">LI - Liechtenstein </option> <option value="LT">LT - Lithuania </option> <option value="LU">LU - Luxembourg </option> <option value="MO">MO - Macau </option> <option value="MK">MK - Macedonia </option> <option value="MG">MG - Madagascar </option> <option value="MW">MW - Malawi </option> <option value="MY">MY - Malaysia </option> <option value="MV">MV - Maldives </option> <option value="ML">ML - Mali </option> <option value="MT">MT - Malta </option> <option value="MH">MH - Marshall Islnds </option> <option value="MQ">MQ - Martinique </option> <option value="MR">MR - Mauretania </option> <option value="MU">MU - Mauritius </option> <option value="YT">YT - Mayotte </option> <option value="MX">MX - Mexico </option> <option value="FM">FM - Micronesia </option> <option value="UM">UM - Minor Outl.Isl. </option> <option value="MD">MD - Moldova </option> <option value="MC">MC - Monaco </option> <option value="MN">MN - Mongolia </option> <option value="MS">MS - Montserrat </option> <option value="MA">MA - Morocco </option> <option value="MZ">MZ - Mozambique </option> <option value="MP">MP - N.Mariana Islnd </option> <option value="NA">NA - Namibia </option> <option value="NR">NR - Nauru </option> <option value="NP">NP - Nepal </option> <option value="NL">NL - Netherlands </option> <option value="NC">NC - New Caledonia </option> <option value="NZ">NZ - New Zealand </option> <option value="NI">NI - Nicaragua </option> <option value="NE">NE - Niger </option> <option value="NG">NG - Nigeria </option> <option value="NU">NU - Niue </option> <option value="NF">NF - Norfolk Islands </option> <option value="KP">KP - North Korea </option> <option value="NO">NO - Norway </option> <option value="OM">OM - Oman </option> <option value="PK">PK - Pakistan </option> <option value="PW">PW - Palau </option> <option value="PS">PS - Palestine </option> <option value="PA">PA - Panama </option> <option value="PG">PG - Pap. New Guinea </option> <option value="PY">PY - Paraguay </option> <option value="PE">PE - Peru </option> <option value="PH">PH - Philippines </option> <option value="PN">PN - Pitcairn Islnds </option> <option value="PL">PL - Poland </option> <option value="PT">PT - Portugal </option> <option value="PR">PR - Puerto Rico </option> <option value="QA">QA - Qatar </option> <option value="CG">CG - Rep.of Congo </option> <option value="RE">RE - Reunion </option> <option value="RO">RO - Romania </option> <option value="RU">RU - Russian Fed. </option> <option value="RW">RW - Rwanda </option> <option value="GS">GS - S. Sandwich Ins </option> <option value="ST">ST - S.Tome,Principe </option> <option value="SH">SH - Saint Helena </option> <option value="WS">WS - Samoa </option> <option value="AS">AS - Samoa, America </option> <option value="SM">SM - San Marino </option> <option value="SA">SA - Saudi Arabia </option> <option value="SN">SN - Senegal </option> <option value="CS">CS - Serbia/Monten. </option> <option value="SC">SC - Seychelles </option> <option value="SL">SL - Sierra Leone </option> <option value="SG">SG - Singapore </option> <option value="SX">SX - Sint Maarten </option> <option value="SK">SK - Slovakia </option> <option value="SI">SI - Slovenia </option> <option value="SB">SB - Solomon Islands </option> <option value="SO">SO - Somalia </option> <option value="ZA">ZA - South Africa </option> <option value="KR">KR - South Korea </option> <option value="SS">SS - South Sudan </option> <option value="ES">ES - Spain </option> <option value="LK">LK - Sri Lanka </option> <option value="KN">KN - St Kitts&Nevis; </option> <option value="LC">LC - St. Lucia </option> <option value="VC">VC - St. Vincent </option> <option value="PM">PM - St.Pier,Miquel. </option> <option value="SD">SD - Sudan </option> <option value="SR">SR - Suriname </option> <option value="SJ">SJ - Svalbard </option> <option value="SZ">SZ - Swaziland </option> <option value="SE">SE - Sweden </option> <option value="CH">CH - Switzerland </option> <option value="SY">SY - Syria </option> <option value="TW">TW - Taiwan </option> <option value="TJ">TJ - Tajikistan </option> <option value="TZ">TZ - Tanzania </option> <option value="TH">TH - Thailand </option> <option value="TG">TG - Togo </option> <option value="TK">TK - Tokelau Islands </option> <option value="TO">TO - Tonga </option> <option value="TT">TT - Trinidad,Tobago </option> <option value="TN">TN - Tunisia </option> <option value="TR">TR - Turkey </option> <option value="TM">TM - Turkmenistan </option> <option value="TC">TC - Turksh Caicosin </option> <option value="TV">TV - Tuvalu </option> <option value="UG">UG - Uganda </option> <option value="UA">UA - Ukraine </option> <option value="GB">GB - United Kingdom </option> <option value="UY">UY - Uruguay </option> <option value="US">US - USA </option> <option value="AE">AE - Utd.Arab Emir. </option> <option value="UZ">UZ - Uzbekistan </option> <option value="VU">VU - Vanuatu </option> <option value="VA">VA - Vatican City </option> <option value="VE">VE - Venezuela </option> <option value="VN">VN - Vietnam </option> <option value="WF">WF - Wallis,Futuna </option> <option value="EH">EH - West Sahara </option> <option value="YE">YE - Yemen </option> <option value="ZM">ZM - Zambia </option> <option value="ZW">ZW - Zimbabwe </option> </select> <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required.gif" alt="Required Field" width="9" height="14" hspace="3"> <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required_blue.gif" alt="Required Field" width="9" height="14" hspace="3"><br><i>(Leave blank for "United States")</i></td> </tr> <tr> <td align="right" class="highlight">Postal Code:</td> <td class="highlight"><input name="POSTAL_CODE" type="text" onfocus="select();"> <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required.gif" alt="Required Field" width="9" height="14" hspace="3"> <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required_blue.gif" alt="Required Field" width="9" height="14" hspace="3"> if a United States address.</td> </tr> <tr> <td align="right">E-Mail:</td> <td><input name="DONOR_EMAIL" type="text" onfocus="select();"> <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required.gif" alt="Required Field" width="9" height="14" hspace="3"></td> </tr> <tr> <td align="right">Home Phone #:</td> <td><input name="HOME_PHONE" type="text" onfocus="select();"> <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required.gif" alt="Required Field" width="9" height="14" hspace="3"></td> </tr> <tr> <td align="right">Duke Class Year:</td> <td><input name="CLASS_YEAR" type="text" onfocus="select();" size="4" maxlength="4"></td> </tr> <tr> <td align="right" class="highlight">Company:</td> <td class="highlight"><input name="COMPANY" type="text" onfocus="select();" size="40"></td> </tr> <tr> <td align="right" class="highlight">Position/Job Title:</td> <td class="highlight"><input name="JOB_TITLE" type="text" onfocus="select();" size="40"></td> </tr> <tr> <td align="right" class="highlight">Work Phone #:</td> <td class="highlight"><input name="WORK_PHONE" type="text" onfocus="select();"></td> </tr> <tr> <td align="right" class="highlight">FAX #:</td> <td class="highlight"><input name="DONOR_FAX" type="text" onfocus="select();"></td> </tr> <tr> <td align="right">Spouse's Name:</td> <td><input name="SPOUSE_NAME" type="text" onfocus="select();" size="40"></td> </tr> <tr> <td align="right">Spouse's Duke Class Year:</td> <td><input name="SPOUSE_CLASS_YEAR" type="text" onfocus="select();" size="4" maxlength="4"></td> </tr> <tr> <td align="right"><img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/spacer.gif" width="200" height="1" border="0"></td> <td width="100%"></td> </tr> </table> <p> <table width="100%" border="0" cellspacing="0" cellpadding="1"> <tr> <td width="100%"><span class="heading1">Broker Information</span></td> </tr> <tr> <td bgcolor="#FFCC33"><img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/spacer.gif" width="1" height="1"></td> </tr> </table> Please enter information about the broker who will make the transfer:<br> <p> <script language="Javascript"> function checkbroker(a) { if (document.frmStockGift.USING_BROKER.checked) { a.blur(); } } function changebroker(a) { frm = document.frmStockGift; usingbroker = a.value; if (usingbroker == 'NO') { frm.BROKER_NAME.value=''; frm.BROKER_FIRM.value=''; frm.BROKER_PHONE.value=''; frm.BROKER_NAME.className="disabledTextArea"; frm.BROKER_FIRM.className="disabledTextArea"; frm.BROKER_PHONE.className="disabledTextArea"; frm.TRANSMITTAL_METHOD.className="enabledTextArea"; if(ie4||ns5){ thisId=document.getElementById('brokerinfo'); thisId.style.display = "none"; thisId2=document.getElementById('nobrokerinfo'); thisId2.style.display = "block"; } } else { // it's not checked, so they ARE using a broker... activate the fields. frm.TRANSMITTAL_METHOD.value=''; frm.TRANSMITTAL_METHOD.className="disabledTextArea"; frm.BROKER_NAME.className="enabledTextArea"; frm.BROKER_FIRM.className="enabledTextArea"; frm.BROKER_PHONE.className="enabledTextArea"; if(ie4||ns5){ thisId=document.getElementById('brokerinfo'); thisId.style.display = "block"; thisId2=document.getElementById('nobrokerinfo'); thisId2.style.display = "none"; } } } </script> <input type="radio" name="USING_BROKER" value="NO" onclick="changebroker(this);"> I am <b>not</b> using a broker for this transaction.<br> <div id="nobrokerinfo" style="display: none;">     How will you be sending the stock? (postal mail, courier, personal delivery, etc.)<br>     <input type="TEXT" id="TRANSMITTAL_METHOD" name="TRANSMITTAL_METHOD" size="40" maxlength="100"><br> </div> <input type="radio" name="USING_BROKER" value="YES" onclick="changebroker(this);" checked> I am using a broker for this transaction.<br> <br> <div id="brokerinfo"> <table border="0" cellpadding="3" cellspacing="0"> <tr> <td align="right" class="highlight">Brokerage/Financial Institution Name:</td> <td class="highlight"><input id="BROKER_FIRM" name="BROKER_FIRM" type="text" onfocus="select();" onfocus="checkbroker(this);" style="width: 250px;"> <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required.gif" alt="Required Field" width="9" height="14" hspace="3"> <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required_blue.gif" alt="Required Field" width="9" height="14" hspace="3"></td> </tr> <tr> <td align="right" class="highlight">Broker/Contact Name:</td> <td class="highlight"><input id="BROKER_NAME" name="BROKER_NAME" type="text" onfocus="select();" onfocus="checkbroker(this);" style="width: 250px;"></td> </tr> <tr> <td align="right" class="highlight">Broker/Contact Phone #:</td> <td class="highlight"><input id="BROKER_PHONE" name="BROKER_PHONE" type="text" onfocus="select();" onfocus="checkbroker(this);" style="width: 250px;"> <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required.gif" alt="Required Field" width="9" height="14" hspace="3"> <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required_blue.gif" alt="Required Field" width="9" height="14" hspace="3"></td> </tr> <tr> <td align="right" class="highlight">Broker/Contact FAX #:</td> <td class="highlight"><input id="BROKER_FAX" name="BROKER_FAX" type="text" onfocus="select();" onfocus="checkbroker(this);" style="width: 250px;"></td> </tr> <tr> <td align="right"><img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/spacer.gif" width="200" height="1" border="0"></td> <td width="100%"></td> </tr> </table> </div> <p> <table width="100%" border="0" cellspacing="0" cellpadding="1"> <tr> <td width="100%"><span class="heading1">About This Gift</span></td> </tr> <tr> <td bgcolor="#FFCC33"><img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/spacer.gif" width="1" height="1"></td> </tr> </table> Please tell us about the gift: <p> Expected date of transfer (mm/dd/yyyy): <input type="text" onfocus="select();" name="TRANSFER_DATEx" size="10" maxlength="10" value=""> <a href="javascript:opencalendar('TRANSFER_DATEx','frmStockGift');"><img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/calendar_icon.gif" border="0" alt="Choose date from calendar."></a> <p> <table cellpadding="2" cellspacing="0" border="0" width="100%"><tr><td class="highlight"> <input type="radio" name="SPECIFIC_STOCK" value="NO" onclick="set_stocks('disable');"> I am unsure of the exact stocks/securities that will be donated. However, I will follow-up with your office once the decision is made. <br> <input type="radio" name="SPECIFIC_STOCK" value="YES" checked onclick="set_stocks('enable');"> I want to donate the following stocks/securities: </td></tr></table> <p> <script language="Javascript"> function checkfocus(a) { if (document.frmStockGift.SPECIFIC_STOCK[0].checked) { a.blur(); } } function set_stocks(what) { if (what == 'disable') { frm = document.frmStockGift; frm.SECURITY_NAME_1.value = ''; frm.SECURITY_NUMSHARES_1.value = ''; frm.SECURITY_VALSHARES_1.value = ''; frm.SECURITY_NAME_2.value = ''; frm.SECURITY_NUMSHARES_2.value = ''; frm.SECURITY_VALSHARES_2.value = ''; frm.SECURITY_NAME_3.value = ''; frm.SECURITY_NUMSHARES_3.value = ''; frm.SECURITY_VALSHARES_3.value = ''; frm.SECURITY_NAME_4.value = ''; frm.SECURITY_NUMSHARES_4.value = ''; frm.SECURITY_VALSHARES_4.value = ''; frm.SECURITY_NAME_1.className="disabledTextArea"; frm.SECURITY_NUMSHARES_1.className="disabledTextArea"; frm.SECURITY_VALSHARES_1.className="disabledTextArea"; frm.SECURITY_NAME_2.className="disabledTextArea"; frm.SECURITY_NUMSHARES_2.className="disabledTextArea"; frm.SECURITY_VALSHARES_2.className="disabledTextArea"; frm.SECURITY_NAME_3.className="disabledTextArea"; frm.SECURITY_NUMSHARES_3.className="disabledTextArea"; frm.SECURITY_VALSHARES_3.className="disabledTextArea"; frm.SECURITY_NAME_4.className="disabledTextArea"; frm.SECURITY_NUMSHARES_4.className="disabledTextArea"; frm.SECURITY_VALSHARES_4.className="disabledTextArea"; if(ie4||ns5){ thisId=document.getElementById('stockinfo'); thisId.style.display = "none"; } } else { frm.SECURITY_NAME_1.className="enabledTextArea"; frm.SECURITY_NUMSHARES_1.className="enabledTextArea"; frm.SECURITY_VALSHARES_1.className="enabledTextArea"; frm.SECURITY_NAME_2.className="enabledTextArea"; frm.SECURITY_NUMSHARES_2.className="enabledTextArea"; frm.SECURITY_VALSHARES_2.className="enabledTextArea"; frm.SECURITY_NAME_3.className="enabledTextArea"; frm.SECURITY_NUMSHARES_3.className="enabledTextArea"; frm.SECURITY_VALSHARES_3.className="enabledTextArea"; frm.SECURITY_NAME_4.className="enabledTextArea"; frm.SECURITY_NUMSHARES_4.className="enabledTextArea"; frm.SECURITY_VALSHARES_4.className="enabledTextArea"; if(ie4||ns5){ thisId=document.getElementById('stockinfo'); thisId.style.display = "block"; } } } </script> <div id="stockinfo"> <table cellpadding="2" cellspacing="2" border="0"> <tr> <td rowspan="6"><img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/spacer.gif" width="20" height="1"></td> <td class="colheader">Stock / Security Name</td> <td class="colheader"># of Shares</td> <td class="colheader">and/or</td> <td class="colheader">$ Approx. Value (USD)</td> </tr> <tr> <td class="highlight"><input name="SECURITY_NAME_1" type="text" onfocus="select();" class="enabledfield" style="width: 350px;" onfocus="checkfocus(this);"></td> <td class="highlight"><input name="SECURITY_NUMSHARES_1" type="text" onfocus="select();" class="enabledfield" style="width: 100px;" onfocus="checkfocus(this);"></td> <td align="center" class="highlight">and/or</td> <td class="highlight">$<input name="SECURITY_VALSHARES_1" type="text" onfocus="select();" class="enabledfield" style="width: 100px;" onfocus="checkfocus(this);">USD</td> </tr> <tr> <td class="highlight"><input name="SECURITY_NAME_2" type="text" onfocus="select();" class="enabledfield" style="width: 350px;" onfocus="checkfocus(this);"></td> <td class="highlight"><input name="SECURITY_NUMSHARES_2" type="text" onfocus="select();" class="enabledfield" style="width: 100px;" onfocus="checkfocus(this);"></td> <td align="center" class="highlight">and/or</td> <td class="highlight">$<input name="SECURITY_VALSHARES_2" type="text" onfocus="select();" class="enabledfield" style="width: 100px;" onfocus="checkfocus(this);">USD</td> </tr> <tr> <td class="highlight"><input name="SECURITY_NAME_3" type="text" onfocus="select();" class="enabledfield" style="width: 350px;" onfocus="checkfocus(this);"></td> <td class="highlight"><input name="SECURITY_NUMSHARES_3" type="text" onfocus="select();" class="enabledfield" style="width: 100px;" onfocus="checkfocus(this);"></td> <td align="center" class="highlight">and/or</td> <td class="highlight">$<input name="SECURITY_VALSHARES_3" type="text" onfocus="select();" class="enabledfield" style="width: 100px;" onfocus="checkfocus(this);">USD</td> </tr> <tr> <td class="highlight"><input name="SECURITY_NAME_4" type="text" onfocus="select();" class="enabledfield" style="width: 350px;" onfocus="checkfocus(this);"></td> <td class="highlight"><input name="SECURITY_NUMSHARES_4" type="text" onfocus="select();" class="enabledfield" style="width: 100px;" onfocus="checkfocus(this);"></td> <td align="center" class="highlight">and/or</td> <td class="highlight">$<input name="SECURITY_VALSHARES_4" type="text" onfocus="select();" class="enabledfield" style="width: 100px;" onfocus="checkfocus(this);">USD</td> </tr> </table> </div> <p> <script language="Javascript"> function check_match_focus(which,a) { frm = document.frmStockGift; if (which == 'donor') { foo = frm.DONOR_COMPANY_MATCH; } else { foo = frm.SPOUSE_COMPANY_MATCH; } if ( ! foo.checked) { a.blur(); } } function set_company_match(which) { frm = document.frmStockGift; if (which == "donor") { if ( ! frm.DONOR_COMPANY_MATCH.checked) { frm.DONOR_MATCH_COMPANY.value = ''; frm.DONOR_MATCH_COMMENTS.value = ''; frm.DONOR_MATCH_COMPANY.className="disabledTextArea"; frm.DONOR_MATCH_COMMENTS.className="disabledTextArea"; if(ie4||ns5){ thisId=document.getElementById('donor_match_info'); thisId.style.display = "none"; } } else { frm.DONOR_MATCH_COMPANY.className="enabledTextArea"; frm.DONOR_MATCH_COMMENTS.className="enabledTextArea"; if(ie4||ns5){ thisId=document.getElementById('donor_match_info'); thisId.style.display = "block"; } } } else { // spouse if ( ! frm.SPOUSE_COMPANY_MATCH.checked) { frm.SPOUSE_MATCH_COMPANY.value = ''; frm.SPOUSE_MATCH_COMMENTS.value = ''; frm.SPOUSE_MATCH_COMPANY.className="disabledTextArea"; frm.SPOUSE_MATCH_COMMENTS.className="disabledTextArea"; if(ie4||ns5){ thisId=document.getElementById('spouse_match_info'); thisId.style.display = "none"; } } else { frm.SPOUSE_MATCH_COMPANY.className="enabledTextArea"; frm.SPOUSE_MATCH_COMMENTS.className="enabledTextArea"; if(ie4||ns5){ thisId=document.getElementById('spouse_match_info'); thisId.style.display = "block"; } } } } </script> <table cellpadding="2" cellspacing="0" border="0" width="100%"><tr><td class="highlight"> <table width="750" border="0" cellspacing="3" cellpadding="0"> <tr> <td width="5%" valign="top"> <input type="checkbox" name="DONOR_COMPANY_MATCH" value="YES" onclick="set_company_match('donor');"> </td> <td width="46%" valign="top"> My Company will match my gift. </td> <td width="2%" valign="top"> <input type="checkbox" name="SPOUSE_COMPANY_MATCH" value="YES" onclick="set_company_match('spouse');"> </td> <td width="47%" valign="top"> My Spouse's Company will match my gift </td> </tr> <tr> <td> </td> <td> <div id="donor_match_info" style="display: none;"> Company Name: <input name="DONOR_MATCH_COMPANY" type="text" onfocus="select();" class="disabledTextArea" id="DONOR_MATCH_COMPANY" onfocus="check_match_focus('donor',this);" style="width: 200px;"> <br><br> Additional Companies or Comments:<br> <textarea name="DONOR_MATCH_COMMENTS" rows="4" wrap="VIRTUAL" class="disabledTextArea" id="DONOR_MATCH_COMMENTS" onfocus="check_match_focus('donor',this);" style="width: 300px;"></textarea> </div> </td> <td> </td> <td> <div id="spouse_match_info" style="display: none;"> Company Name: <input name="SPOUSE_MATCH_COMPANY" type="text" onfocus="select();" class="disabledTextArea" id="SPOUSE_MATCH_COMPANY" onfocus="check_match_focus('spouse',this);" style="width: 200px;"> <br><br> Additional Companies or Comments:<br> <textarea name="SPOUSE_MATCH_COMMENTS" rows="4" wrap="VIRTUAL" class="disabledTextArea" id="SPOUSE_MATCH_COMMENTS" onfocus="check_match_focus('spouse',this);" style="width: 300px;"></textarea> </div> </td> </tr> </table> </td></tr></table> <p> <table cellpadding="2" cellspacing="0" border="0" width="100%"><tr><td class="highlight"> <table width="100%" border="0" align="center" cellpadding="3" cellspacing="0"> <tr> <td class="highlight"> Designate my Gift to the following: <p> If more than one designation is specified, your gift will be divided equally unless other instructions are provided in the comment section below. </td> </tr> </table> <table width="100%" border="0" align="center" cellpadding="3" cellspacing="0"> <tr> <td width="22%" align="right" valign="top" class="highlight"> Gift Designations: </td> <td width="78%" class="highlight"> 1. <input name="OTHER_DESIGNATION_1" type="text" onfocus="select();" size="60"> <br> <br> 2. <input name="OTHER_DESIGNATION_2" type="text" onfocus="select();" size="60"> <br> <br> 3. <input name="OTHER_DESIGNATION_3" type="text" onfocus="select();" size="60"> <br> <br> 4. <input name="OTHER_DESIGNATION_4" type="text" onfocus="select();" size="60"> </td> </tr> </table> <p> If you are unsure of where you'd like to designate your gift, below are a list of commonly used designations. Check all that apply. <p> <script language="Javascript"> function toggle_designation_options(a) { frm = document.frmStockGift; designation_action = a.value; if (ie4||ns5) { if (designation_action == '0') { thisId=document.getElementById('designation_options'); thisId.style.display = "none"; } else { thisId=document.getElementById('designation_options'); thisId.style.display = "block"; } } } </script> <fieldset> <legend><b>Gift Designation Options</b></legend> <input type="radio" name="DESIGNATIONS_ACTION" value="1" onclick="toggle_designation_options(this);">Show options   <input type="radio" checked name="DESIGNATIONS_ACTION" value="0" onclick="toggle_designation_options(this);">Hide options <div id="designation_options" style="display: none;"> <p> <table width="100%" border="0" align="center" cellpadding="3" cellspacing="0"> <tr> <td class="highlight" width="50%" valign="top"> <fieldset> <legend><b>School Annual Funds</b></legend> <input type="checkbox" name="DESIGNATIONS" value="113-1010">Divinity School<br> <input type="checkbox" name="DESIGNATIONS" value="113-1006">Fuqua School of Business<br> <input type="checkbox" name="DESIGNATIONS" value="113-1025">Graduate School Arts & Sciences<br> <input type="checkbox" name="DESIGNATIONS" value="113-1030">Law School<br> <input type="checkbox" name="DESIGNATIONS" value="113-1051">Nicholas School of Environment & Earth Sciences<br> <input type="checkbox" name="DESIGNATIONS" value="113-1015 or 113-1016">Pratt School of Engineering<br> <input type="checkbox" name="DESIGNATIONS" value="113-1040">School of Nursing<br> <input type="checkbox" name="DESIGNATIONS" value="113-1045">Trinity College Arts & Sciences<br> </fieldset> <br> <fieldset> <legend><b>Medical Center Annual Funds</b></legend> <input type="checkbox" name="DESIGNATIONS" value="113-1035">The Fund for DukeMed - Where the Need is Greatest<br> <input type="checkbox" name="DESIGNATIONS" value="398-5100">Medical Ann. Fund/Davison Club Scholarship Fund<br> <input type="checkbox" name="DESIGNATIONS" value="113-1036">Davison Club<br> <input type="checkbox" name="DESIGNATIONS" value="399-1362">Care & Discovery Fund<br> <input type="checkbox" name="DESIGNATIONS" value="399-1862">Medical Families Fund<br> <input type="checkbox" name="DESIGNATIONS" value="School of Nursing Annual Fund (scholarships)">School of Nursing Annual Fund (scholarships)<br> </fieldset> <br> <fieldset> <legend><b>Other Annual Funds</b></legend> <input type="checkbox" name="DESIGNATIONS" value="113-1080">Art Museum<br> <input type="checkbox" name="DESIGNATIONS" value="399-1571">The Chapel<br> <input type="checkbox" name="DESIGNATIONS" value="399-2854">The Gardens<br> <input type="checkbox" name="DESIGNATIONS" value="113-1070">The Library<br> <input type="checkbox" name="DESIGNATIONS" value="113-1091">Marine Lab<br> </fieldset> </td> <td class="highlight" width="50%" valign="top"> <fieldset> <legend><b>Non Annual Fund Designations</b></legend> <input type="checkbox" name="DESIGNATIONS" value="451-6008">Duke University Medical Center General Support<br> <input type="checkbox" name="DESIGNATIONS" value="Duke Comprehensive Cancer Center">Duke Comprehensive Cancer Center<br> <input type="checkbox" name="DESIGNATIONS" value="399-1634">Duke Children's<br> <input type="checkbox" name="DESIGNATIONS" value="397-7000">Duke Primate Center<br> <input type="checkbox" name="DESIGNATIONS" value="611-2657">General Arts & Sciences Endowment<br> </fieldset> <br> <fieldset> <legend><b>Dues</b></legend> <input type="checkbox" name="DESIGNATIONS" value="850-0310">Duke University Alumni Association Dues ($50/yr)<br> <input type="checkbox" name="DESIGNATIONS" value="397-5002 or 397-5003">Medical Alumni Association (MAA) Dues<br> <input type="checkbox" name="DESIGNATIONS" value="850-0535">Engineering<br> <input type="checkbox" name="DESIGNATIONS" value="850-1415">School of Nursing Alumni Association Dues ($20/yr)<br> </fieldset> <br> <fieldset> <legend><b>Athletics</b></legend> <input type="checkbox" name="DESIGNATIONS" value="398-2800">Iron Dukes<br> <input type="checkbox" name="DESIGNATIONS" value="Varsity Club - sports specific">Varsity Club - sports specific<br> <input type="checkbox" name="DESIGNATIONS" value="Athletic Capital Campaign">Athletic Capital Campaigns<br> </fieldset> <br> </td> </tr> </table> </div> </fieldset> <table width="100%" border="0" align="center" cellpadding="3" cellspacing="0"> <tr> <td colspan="2" valign="top" class="highlight"> <br>Additional Comments Regarding Designations: (optional)<br> <textarea name="DESIGNATION_COMMENTS" cols="80" rows="5" wrap="VIRTUAL"></textarea> </td> </tr> </table> <table width="100%" border="0" align="center" cellpadding="3" cellspacing="0"> <tr> <td valign="top" class="highlight"> <br>Bot test: Four plus five is what?<br> <input type="text" name="BOT_TEST" cols="80" rows="5" wrap="VIRTUAL"> <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required.gif" alt="Required Field" width="9" height="14" hspace="3"> <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/required_blue.gif" alt="Required Field" width="9" height="14" hspace="3"> </td> </tr> </table> </td></tr></table> <p> <table width="100%" border="0" cellspacing="0" cellpadding="1"> <tr> <td width="100%"><span class="heading1">Submit This Form</span></td> </tr> <tr> <td bgcolor="#FFCC33"><img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/spacer.gif" width="1" height="1"></td> </tr> </table> Submit this form to send this information to Duke University's Alumni & Development Records office. <p> <script language="Javascript"> document.writeln("<INPUT TYPE=SUBMIT VALUE=\"Submit Form\">  "); </script> <input type="RESET" value="Clear Form"> </td> </tr> </table> </form> <img src="/web/20160213143634im_/https://www.stockgifts.duke.edu/include/spacer.gif" width="1" height="200" border="0"> </body> </html>