Your First Name (required):

Your Last Name:

Your Company Name:

Position:

Your Mailing Address:

Your Country:

Your Phone:

Your Email (required):

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Your Adjusted Gross Income as reported last year: $

Your Estimated Net Worth (USD): $

Your Liquid Cash and Cash Equivalents (USD): $

Years experience investing or trading stocks, futures, options, bonds: 1-5 years5-10 years10-20 years20+ years

I declare under penalty of perjury that the above data is true and correct. I hereby affirm this information to be accurate to the best of my knowledge.