Gift of securities to Brain Canada Foundation

To transfer securities to Brain Canada Foundation electronically, please complete sections A, B and C of this form and return the original signed copy to Brain Canada Foundation by email or by mail to:

Mario Chartrand – Director of Finance 1200 McGill College Avenue, Suite 1600 Montreal, QC, H3B 4G7
Phone: (514) 989-2989 ext. 102
Email: mario.chartrand@braincanada.ca

Your tax receipt will be in the amount of the closing trading price on the date that the shares are received. These securities have been donated to Brain Canada Foundation without restriction.

(A)	My contact Information

Full Name		
Home phone			
	Street Address Including City, Province and Postal code		
Business phone			
	Email address					

(B)	My broker’s contact information

Name or firm		
Contact name		
Street Address Including City, Province and Postal code		
Phone number		
Email address				

(C)	Information about my brokerage account and the securities to be donated
Name or security		# of units donated		
Brokerage account number		

Information for the transferring institution
Broker: RBC Dominion Securities
Branch: 1 Place Ville-Marie, Suite 300, Montreal, QC H3B 4R8
Care of : Eric Machado, Associate Advisor T. 514-878-8104

FINS#: T002 CUID #: DOMA DTC # : 5002
Transit #: 90328
Account #: 301-79209-13
Account name: Brain Canada Foundation FND#1

Signature	Date	
Signature of the Person Submitting this Form	MM/DD/YY	

Charitable Registration No. 89105 2094 RR0001