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Form analysis
2 forms found in the DOM

POST https://hushforms.com/stthomas

<form method="post" action="https://hushforms.com/stthomas" enctype="multipart/form-data" autocomplete="off" class="compact-layout secure-form" id="element_secure-form">
  <div class="form-inner-container element_form-inner-container">
    <div class="page-error-message hide" id="element_page-error-message">
      <div class="container"> Please correct the errors described below. </div>
    </div>
    <div class="presentation-block normal-top-margin no-bottom-margin element_body-contents application-size-fonts secure-form">
      <div class="container">
        <div class="row">
          <div class="col-md-8">
            <input type="hidden" name="hosted" value="1">
            <div style="position: absolute; left: -5000px;" aria-hidden="true"><textarea name="ea6586015aa694444d9189087a7013e4" autocomplete="false" tabindex="-1"></textarea></div>
            <div class="important-information hidden-lg hidden-md">
              <div>
                <h3>Raymond D. Cotton and Associates 1629 K Street, NW, Suite 300 Washington, D.C. 20006</h3>
                <p>TEL 202.827.9990 | FAX 202.827.9994 RDC@RaymondCotton.com </p>
                <ul>
                  <li>In order to see your current ranking of salary and compensation please fill out the form and click Submit. </li>
                  <li>On behalf of the University of St. Thomas we thank you for participating in this important study. </li>
                  <li>Questions/Problems? Call Brandon Cobblestone at (561) 271-9592</li>
                </ul>
              </div>
            </div>
            <div class="form-grid-container responsive">
              <div class="form-grid-row first-row">
                <div class="custom-controls">
                  <div>
                    <div class="form-grid-control-cell form-grid-control-width-30 cell-control-type-textinput first-in-row last-in-row">
                      <div class="visibility-container">
                        <div class="form-group">
                          <label for="field-1-0" class="required">
                            <span class="label-text">President's Name</span>
                          </label>
                          <input data-visibility-field-name="formfield2" data-visibility-field-type="textinput" class="form-control" type="text" id="field-1-0" name="formfield2" placeholder="" value="" data-validation-required="1"
                            data-validation-field-type="textinput" data-validation="1" data-validation-required-message="You must enter a value for this field" data-validation-email-message="Please enter a valid email address"
                            data-validation-number-message="Please enter a valid number" data-has-field-name="" data-has-field-id="" autocomplete="off">
                          <span class="hushform-message_secureFormObj hushform_secureFormObj_formfield2 inline-validation-message ">
                          </span>
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                    <div class="form-grid-control-cell filler"></div>
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              </div>
              <div class="form-grid-row ">
                <div class="custom-controls">
                  <div>
                    <div class="form-grid-control-cell form-grid-control-width-30 cell-control-type-textinput first-in-row last-in-row">
                      <div class="visibility-container">
                        <div class="form-group">
                          <label for="field-1-1" class="required">
                            <span class="label-text">Institution Name</span>
                          </label>
                          <input data-visibility-field-name="formfield1" data-visibility-field-type="textinput" class="form-control" type="text" id="field-1-1" name="formfield1" placeholder="" value="" data-validation-required="1"
                            data-validation-field-type="textinput" data-validation="1" data-validation-required-message="You must enter a value for this field" data-validation-email-message="Please enter a valid email address"
                            data-validation-number-message="Please enter a valid number" data-has-field-name="" data-has-field-id="" autocomplete="off">
                          <span class="hushform-message_secureFormObj hushform_secureFormObj_formfield1 inline-validation-message ">
                          </span>
                        </div>
                      </div>
                    </div>
                    <div class="form-grid-control-cell filler"></div>
                  </div>
                </div>
              </div>
              <div class="form-grid-row ">
                <div class="custom-controls">
                  <div>
                    <div class="form-grid-control-cell form-grid-control-width-10 cell-control-type-number first-in-row last-in-row">
                      <div class="visibility-container">
                        <div class="form-group">
                          <label for="field-1-2">
                            <span class="label-text">How many years is your contract? </span>
                          </label>
                          <input data-visibility-field-name="formfield10" data-visibility-field-type="number" class="form-control" type="number" id="field-1-2" name="formfield10" data-has-field-name="" data-has-field-id="" maxlength="80"
                            placeholder="" value="" step="1" data-validation-required="" data-validation-field-type="number" data-validation="1" data-validation-required-message="You must enter a value for this field"
                            data-validation-email-message="Please enter a valid email address" data-validation-number-message="Please enter a valid number" autocomplete="off">
                          <span class="hushform-message_secureFormObj hushform_secureFormObj_formfield10 inline-validation-message ">
                          </span>
                        </div>
                      </div>
                    </div>
                    <div class="form-grid-control-cell filler"></div>
                  </div>
                </div>
              </div>
              <div class="form-grid-row ">
                <div class="custom-controls">
                  <div>
                    <div class="form-grid-control-cell form-grid-control-width-30 cell-control-type-textinput first-in-row last-in-row">
                      <div class="visibility-container">
                        <div class="form-group">
                          <label for="field-1-3" class="required">
                            <span class="label-text">Base Salary</span>
                          </label>
                          <input data-visibility-field-name="formfield11" data-visibility-field-type="textinput" class="form-control" type="text" id="field-1-3" name="formfield11" placeholder="$" value="" data-validation-required="1"
                            data-validation-field-type="textinput" data-validation="1" data-validation-required-message="You must enter a value for this field" data-validation-email-message="Please enter a valid email address"
                            data-validation-number-message="Please enter a valid number" data-has-field-name="" data-has-field-id="" autocomplete="off">
                          <span class="hushform-message_secureFormObj hushform_secureFormObj_formfield11 inline-validation-message ">
                          </span>
                        </div>
                      </div>
                    </div>
                    <div class="form-grid-control-cell filler"></div>
                  </div>
                </div>
              </div>
              <div class="form-grid-row ">
                <div class="custom-controls">
                  <div>
                    <div class="form-grid-control-cell form-grid-control-width-20 cell-control-type-textinput first-in-row last-in-row">
                      <div class="visibility-container">
                        <div class="form-group">
                          <label for="field-1-4" class="required">
                            <span class="label-text">Bonus</span>
                          </label>
                          <input data-visibility-field-name="formfield9" data-visibility-field-type="textinput" class="form-control" type="text" id="field-1-4" name="formfield9" placeholder="Amount and year of most recently recieved, if any."
                            value="" data-validation-required="1" data-validation-field-type="textinput" data-validation="1" data-validation-required-message="You must enter a value for this field"
                            data-validation-email-message="Please enter a valid email address" data-validation-number-message="Please enter a valid number" data-has-field-name="" data-has-field-id="" autocomplete="off">
                          <span class="hushform-message_secureFormObj hushform_secureFormObj_formfield9 inline-validation-message ">
                          </span>
                          <div class="field-comment"><span class="field-description-block">Year / Amount</span></div>
                        </div>
                      </div>
                    </div>
                    <div class="form-grid-control-cell filler"></div>
                  </div>
                </div>
              </div>
              <div class="form-grid-row ">
                <div class="custom-controls">
                  <div>
                    <div class="form-grid-control-cell form-grid-control-width-30 cell-control-type-textinput first-in-row last-in-row">
                      <div class="visibility-container">
                        <div class="form-group">
                          <label for="field-1-5" class="required">
                            <span class="label-text">Retirement</span>
                          </label>
                          <input data-visibility-field-name="formfield12" data-visibility-field-type="textinput" class="form-control" type="text" id="field-1-5" name="formfield12" placeholder="403(b), 457(b), 457(f) and other deferred compensation"
                            value="" data-validation-required="1" data-validation-field-type="textinput" data-validation="1" data-validation-required-message="You must enter a value for this field"
                            data-validation-email-message="Please enter a valid email address" data-validation-number-message="Please enter a valid number" data-has-field-name="" data-has-field-id="" autocomplete="off">
                          <span class="hushform-message_secureFormObj hushform_secureFormObj_formfield12 inline-validation-message ">
                          </span>
                        </div>
                      </div>
                    </div>
                    <div class="form-grid-control-cell filler"></div>
                  </div>
                </div>
              </div>
              <div class="form-grid-row ">
                <div class="custom-controls">
                  <div>
                    <div class="form-grid-control-cell form-grid-control-width-30 cell-control-type-paragraph first-in-row last-in-row">
                      <div class="visibility-container">
                        <div data-visibility-field-name="formfield13" data-visibility-field-type="paragraph" data-has-field-data-name="" data-name="formfield13">
                          <h2>Perks</h2>
                        </div>
                      </div>
                    </div>
                    <div class="form-grid-control-cell filler"></div>
                  </div>
                </div>
              </div>
              <div class="form-grid-row ">
                <div class="custom-controls">
                  <div>
                    <div class="form-grid-control-cell form-grid-control-width-30 cell-control-type-textinput first-in-row last-in-row">
                      <div class="visibility-container">
                        <div class="form-group">
                          <label for="field-1-7" class="required">
                            <span class="label-text">USD value of all Perks and other income from your instituion</span>
                          </label>
                          <input data-visibility-field-name="formfield17" data-visibility-field-type="textinput" class="form-control" type="text" id="field-1-7" name="formfield17" placeholder="$USD per annum" value="" data-validation-required="1"
                            data-validation-field-type="textinput" data-validation="1" data-validation-required-message="You must enter a value for this field" data-validation-email-message="Please enter a valid email address"
                            data-validation-number-message="Please enter a valid number" data-has-field-name="" data-has-field-id="" autocomplete="off">
                          <span class="hushform-message_secureFormObj hushform_secureFormObj_formfield17 inline-validation-message ">
                          </span>
                        </div>
                      </div>
                    </div>
                    <div class="form-grid-control-cell filler"></div>
                  </div>
                </div>
              </div>
              <div class="form-grid-row ">
                <div class="custom-controls">
                  <div>
                    <div class="form-grid-control-cell form-grid-control-width-10 cell-control-type-radio first-in-row ">
                      <div class="visibility-container">
                        <div class="form-group">
                          <label for="field-1-8">
                            <span class="label-text">Is a house provided?</span>
                          </label>
                          <span class="hushform-message_secureFormObj hushform_secureFormObj_formfield14 inline-validation-message ">
                          </span>
                          <div class="control-columns clearfix" data-control-columns="" data-validation-required="" data-validation-field-type="radio" data-validation="1" data-validation-required-message="You must enter a value for this field"
                            data-validation-email-message="Please enter a valid email address" data-validation-number-message="Please enter a valid number" data-visibility-field-name="formfield14" data-visibility-field-type="radio">
                            <div class="control-column">
                              <div class="radio-or-checkbox-list horizontal  ">
                                <label class="radio custom" data-control-column-item="1">
                                  <input type="radio" name="formfield14" value="Yes" data-has-field-name="" autocomplete="off"> <span>Yes</span>
                                </label>
                                <label class="radio custom" data-control-column-item="1">
                                  <input type="radio" name="formfield14" value="No" data-has-field-name="" autocomplete="off"> <span>No</span>
                                </label>
                              </div>
                            </div>
                          </div>
                        </div>
                      </div>
                    </div>
                    <div class="form-grid-control-cell form-grid-control-width-10 cell-control-type-radio  ">
                      <div class="visibility-container">
                        <div class="form-group">
                          <label for="field-2-8">
                            <span class="label-text">Is an automobile provided?</span>
                          </label>
                          <span class="hushform-message_secureFormObj hushform_secureFormObj_formfield15 inline-validation-message ">
                          </span>
                          <div class="control-columns clearfix" data-control-columns="" data-validation-required="" data-validation-field-type="radio" data-validation="1" data-validation-required-message="You must enter a value for this field"
                            data-validation-email-message="Please enter a valid email address" data-validation-number-message="Please enter a valid number" data-visibility-field-name="formfield15" data-visibility-field-type="radio">
                            <div class="control-column">
                              <div class="radio-or-checkbox-list horizontal  ">
                                <label class="radio custom" data-control-column-item="1">
                                  <input type="radio" name="formfield15" value="Yes" data-has-field-name="" autocomplete="off"> <span>Yes</span>
                                </label>
                                <label class="radio custom" data-control-column-item="1">
                                  <input type="radio" name="formfield15" value="No" data-has-field-name="" autocomplete="off"> <span>No</span>
                                </label>
                              </div>
                            </div>
                          </div>
                        </div>
                      </div>
                    </div>
                    <div class="form-grid-control-cell form-grid-control-width-10 cell-control-type-radio  last-in-row">
                      <div class="visibility-container">
                        <div class="form-group">
                          <label for="field-3-8">
                            <span class="label-text">Are membership dues paid for?</span>
                          </label>
                          <span class="hushform-message_secureFormObj hushform_secureFormObj_formfield16 inline-validation-message ">
                          </span>
                          <div class="control-columns clearfix" data-control-columns="" data-validation-required="" data-validation-field-type="radio" data-validation="1" data-validation-required-message="You must enter a value for this field"
                            data-validation-email-message="Please enter a valid email address" data-validation-number-message="Please enter a valid number" data-visibility-field-name="formfield16" data-visibility-field-type="radio">
                            <div class="control-column">
                              <div class="radio-or-checkbox-list horizontal  ">
                                <label class="radio custom" data-control-column-item="1">
                                  <input type="radio" name="formfield16" value="Yes" data-has-field-name="" autocomplete="off"> <span>Yes</span>
                                </label>
                                <label class="radio custom" data-control-column-item="1">
                                  <input type="radio" name="formfield16" value="No" data-has-field-name="" autocomplete="off"> <span>No</span>
                                </label>
                              </div>
                            </div>
                          </div>
                        </div>
                      </div>
                    </div>
                    <div class="form-grid-control-cell filler"></div>
                  </div>
                </div>
              </div>
              <div class="form-grid-row ">
                <div class="custom-controls">
                  <div>
                    <div class="form-grid-control-cell form-grid-control-width-30 cell-control-type-textarea first-in-row last-in-row">
                      <div class="visibility-container">
                        <div class="form-group">
                          <label for="field-1-9">
                            <span class="label-text">Other compensation and benefits your recieve, including post-presidency benefits (if any)</span>
                          </label> <textarea class="form-control" id="field-1-9" name="formfield18" data-has-field-name="" data-has-field-id="" rows="5" placeholder="" data-validation-required="" data-validation-field-type="textarea"
                            data-validation="1" data-validation-required-message="You must enter a value for this field" data-validation-email-message="Please enter a valid email address" data-validation-number-message="Please enter a valid number"
                            data-visibility-field-name="formfield18" data-visibility-field-type="textarea" autocomplete="off"></textarea>
                          <span class="hushform-message_secureFormObj hushform_secureFormObj_formfield18 inline-validation-message ">
                          </span>
                        </div>
                      </div>
                    </div>
                    <div class="form-grid-control-cell filler"></div>
                  </div>
                </div>
              </div>
              <div class="form-grid-row ">
                <div class="custom-controls">
                  <div>
                    <div class="form-grid-control-cell form-grid-control-width-30 cell-control-type-textinput first-in-row last-in-row">
                      <div class="visibility-container">
                        <div class="form-group">
                          <label for="field-1-10">
                            <span class="label-text">Spousal Compensation (if employed by the institution)</span>
                          </label>
                          <input data-visibility-field-name="formfield19" data-visibility-field-type="textinput" class="form-control" type="text" id="field-1-10" name="formfield19" placeholder="" value="" data-validation-required=""
                            data-validation-field-type="textinput" data-validation="1" data-validation-required-message="You must enter a value for this field" data-validation-email-message="Please enter a valid email address"
                            data-validation-number-message="Please enter a valid number" data-has-field-name="" data-has-field-id="" autocomplete="off">
                          <span class="hushform-message_secureFormObj hushform_secureFormObj_formfield19 inline-validation-message ">
                          </span>
                        </div>
                      </div>
                    </div>
                    <div class="form-grid-control-cell filler"></div>
                  </div>
                </div>
              </div>
              <div class="form-grid-row ">
                <div class="custom-controls">
                  <div>
                    <div class="form-grid-control-cell form-grid-control-width-30 cell-control-type-horizontalline first-in-row last-in-row">
                      <div class="visibility-container">
                        <div data-visibility-field-name="formfield7" data-visibility-field-type="horizontalline" class="
	form-horizontal-line
	"></div>
                      </div>
                    </div>
                    <div class="form-grid-control-cell filler"></div>
                  </div>
                </div>
              </div>
              <div class="form-grid-row ">
                <div class="custom-controls">
                  <div>
                    <div class="form-grid-control-cell form-grid-control-width-30 cell-control-type-paragraph first-in-row last-in-row">
                      <div class="visibility-container">
                        <div data-visibility-field-name="formfield20" data-visibility-field-type="paragraph" data-has-field-data-name="" data-name="formfield20">
                          <h2><strong>Institutional Data</strong></h2>
                        </div>
                      </div>
                    </div>
                    <div class="form-grid-control-cell filler"></div>
                  </div>
                </div>
              </div>
              <div class="form-grid-row ">
                <div class="custom-controls">
                  <div>
                    <div class="form-grid-control-cell form-grid-control-width-30 cell-control-type-fileattachments first-in-row last-in-row">
                      <div class="visibility-container">
                        <div class="form-group">
                          <label for="field-1-13">
                            <span class="label-text">Your most recent Form 990 is requested</span>
                            <span class="field-description-block">Please upload your latest Form 990 here. If you don't have it, please answer the financial questions below.</span>
                          </label>
                          <div data-visibility-field-name="formfield3" data-visibility-field-type="fileattachments" class="form-file-attachments-v2 element_file-attachments" data-allow-multiple="1" data-file-name="formfield3"
                            data-max-file-uploads="20" data-validation-max-file-uploads-exceeded="You cannot attach more than 20 files to this form." data-max-file-upload-size="78643200"
                            data-validation-max-file-upload-size-exceeded="The combined size of your uploads can not exceed 75.0 MB" data-validation-required="" data-validation-field-type="fileattachments" data-validation="1"
                            data-validation-required-message="Please select a file" data-validation-email-message="Please enter a valid email address" data-validation-number-message="Please enter a valid number">
                            <ul></ul>
                            <label class="add-attachment element_add-attachment"><input type="file" class="element_master-input" tabindex="-1" name="formfield3"><span>Add file</span></label>
                            <span class="inline-validation-message">
                              <div class="inline-error">Please upload a file</div>
                            </span>
                          </div>
                        </div>
                      </div>
                    </div>
                    <div class="form-grid-control-cell filler"></div>
                  </div>
                </div>
              </div>
              <div class="form-grid-row ">
                <div class="custom-controls">
                  <div>
                    <div class="form-grid-control-cell form-grid-control-width-30 cell-control-type-horizontalline first-in-row last-in-row">
                      <div class="visibility-container">
                        <div data-visibility-field-name="formfield25" data-visibility-field-type="horizontalline" class="
	form-horizontal-line
	"></div>
                      </div>
                    </div>
                    <div class="form-grid-control-cell filler"></div>
                  </div>
                </div>
              </div>
              <div class="form-grid-row ">
                <div class="custom-controls">
                  <div>
                    <div class="form-grid-control-cell form-grid-control-width-6 cell-control-type-paragraph first-in-row ">
                      <div class="visibility-container">
                        <div data-visibility-field-name="formfield24" data-visibility-field-type="paragraph" data-has-field-data-name="" data-name="formfield24">
                          <p><strong>In lieu of your 990, could you please input basic financials:<br></strong></p>
                        </div>
                      </div>
                    </div>
                    <div class="form-grid-control-cell form-grid-control-width-8 cell-control-type-textinput  ">
                      <div class="visibility-container">
                        <div class="form-group">
                          <label for="field-2-15">
                            <span class="label-text">Annual Revenue</span>
                          </label>
                          <input data-visibility-field-name="formfield4" data-visibility-field-type="textinput" class="form-control" type="text" id="field-2-15" name="formfield4" placeholder="$M" value="" data-validation-required=""
                            data-validation-field-type="textinput" data-validation="1" data-validation-required-message="You must enter a value for this field" data-validation-email-message="Please enter a valid email address"
                            data-validation-number-message="Please enter a valid number" data-has-field-name="" data-has-field-id="" autocomplete="off">
                          <span class="hushform-message_secureFormObj hushform_secureFormObj_formfield4 inline-validation-message ">
                          </span>
                          <div class="field-comment"><span class="field-description-block">Your institution's revenue</span></div>
                        </div>
                      </div>
                    </div>
                    <div class="form-grid-control-cell form-grid-control-width-8 cell-control-type-textinput  ">
                      <div class="visibility-container">
                        <div class="form-group">
                          <label for="field-3-15">
                            <span class="label-text">Endowment</span>
                          </label>
                          <input data-visibility-field-name="formfield5" data-visibility-field-type="textinput" class="form-control" type="text" id="field-3-15" name="formfield5" placeholder="$M" value="" data-validation-required=""
                            data-validation-field-type="textinput" data-validation="1" data-validation-required-message="You must enter a value for this field" data-validation-email-message="Please enter a valid email address"
                            data-validation-number-message="Please enter a valid number" data-has-field-name="" data-has-field-id="" autocomplete="off">
                          <span class="hushform-message_secureFormObj hushform_secureFormObj_formfield5 inline-validation-message ">
                          </span>
                          <div class="field-comment"><span class="field-description-block">Endowment beginning this FY</span></div>
                        </div>
                      </div>
                    </div>
                    <div class="form-grid-control-cell form-grid-control-width-8 cell-control-type-textinput  last-in-row">
                      <div class="visibility-container">
                        <div class="form-group">
                          <label for="field-4-15">
                            <span class="label-text">Assets</span>
                          </label>
                          <input data-visibility-field-name="formfield23" data-visibility-field-type="textinput" class="form-control" type="text" id="field-4-15" name="formfield23" placeholder="$M" value="" data-validation-required=""
                            data-validation-field-type="textinput" data-validation="1" data-validation-required-message="You must enter a value for this field" data-validation-email-message="Please enter a valid email address"
                            data-validation-number-message="Please enter a valid number" data-has-field-name="" data-has-field-id="" autocomplete="off">
                          <span class="hushform-message_secureFormObj hushform_secureFormObj_formfield23 inline-validation-message ">
                          </span>
                          <div class="field-comment"><span class="field-description-block">Total Assets</span></div>
                        </div>
                      </div>
                    </div>
                    <div class="form-grid-control-cell filler"></div>
                  </div>
                </div>
              </div>
              <div class="form-grid-row ">
                <div class="custom-controls">
                  <div>
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	form-horizontal-line
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                                    <input type="checkbox" name="formfield26[]" value="Yes" data-has-field-name="checkbox-list" autocomplete="off"> <span></span> Yes </label>
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                    <h3>Raymond D. Cotton and Associates 1629 K Street, NW, Suite 300 Washington, D.C. 20006</h3>
                    <p>TEL 202.827.9990 | FAX 202.827.9994 RDC@RaymondCotton.com </p>
                    <ul>
                      <li>In order to see your current ranking of salary and compensation please fill out the form and click Submit. </li>
                      <li>On behalf of the University of St. Thomas we thank you for participating in this important study. </li>
                      <li>Questions/Problems? Call Brandon Cobblestone at (561) 271-9592</li>
                    </ul>
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</form>

Text Content

 * 


UNIVERSITY OF ST. THOMAS CONFIDENTIAL COMPENSATION STUDY

Compensation Response Form

Please correct the errors described below.


RAYMOND D. COTTON AND ASSOCIATES 1629 K STREET, NW, SUITE 300 WASHINGTON, D.C.
20006

TEL 202.827.9990 | FAX 202.827.9994 RDC@RaymondCotton.com

 * In order to see your current ranking of salary and compensation please fill
   out the form and click Submit.
 * On behalf of the University of St. Thomas we thank you for participating in
   this important study.
 * Questions/Problems? Call Brandon Cobblestone at (561) 271-9592

President's Name

Institution Name

How many years is your contract?

Base Salary

Bonus
Year / Amount

Retirement



PERKS


USD value of all Perks and other income from your instituion

Is a house provided?
Yes No
Is an automobile provided?
Yes No
Are membership dues paid for?
Yes No

Other compensation and benefits your recieve, including post-presidency benefits
(if any)

Spousal Compensation (if employed by the institution)




INSTITUTIONAL DATA


Your most recent Form 990 is requested Please upload your latest Form 990 here.
If you don't have it, please answer the financial questions below.
Add file
Please upload a file



In lieu of your 990, could you please input basic financials:


Annual Revenue
Your institution's revenue
Endowment
Endowment beginning this FY
Assets
Total Assets


Enrollment
What is your enrollment this year?


Would you like to recieve a redacted version of the study?
Yes
No
Email address


Your information will be encrypted.


RAYMOND D. COTTON AND ASSOCIATES 1629 K STREET, NW, SUITE 300 WASHINGTON, D.C.
20006

TEL 202.827.9990 | FAX 202.827.9994 RDC@RaymondCotton.com

 * In order to see your current ranking of salary and compensation please fill
   out the form and click Submit.
 * On behalf of the University of St. Thomas we thank you for participating in
   this important study.
 * Questions/Problems? Call Brandon Cobblestone at (561) 271-9592

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ELECTRONIC SIGNATURE

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Drop image file here or click to select file Click here to select image file
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I request that my signature be represented by the above electronic signature and
consent to recipients of electronic documents that I sign receiving personal
information about me, including my email and IP addresses.
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