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Name

Address

Email

Phone Number

Instrument in Which You Request Further Information

Current Client

Yes No

Financial Liquidity

<10,000 10,000-50,000 50,000-100,000 100,000+

Total Annual Income

<10,000 10,000-50,000 50,000-100,000 100,000+

Employment Status

Employee Owner Retired Unemployed

Experience In Forex, Cfd's Or Other Instruments

Yes No

Please Indicate The Amount You Are Comfortable Investing

<10,000 10,000-50,000 50,000-100,000 100,000+

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