| Full Name (First, Last) |
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Company Name, if any |
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Street Address |
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| City |
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| Postal Code |
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| Country |
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| Telephone Number (Home) |
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| Telephone Number (Mobile) |
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| E-mail Address |
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| Date of Birth |
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| Are you interested in Introducing Broker opportunities for yourself or for your Company? |
My Company will act as IB
I will personally act as IB
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| How would you describe your current position as an Introducing Broker or Market participant? |
Beginner - Starting to explore opportunities and gather Information
Intermediate - Have begun to build business / obtain clients
Advanced - I have an existing business with clients currently trading
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| If 'Advanced' what is your estimate of your clients' current monthly trading volume? |
USD per month |
| What is the website address of your business, if any? |
http:// |
| What other information can you provide us about your existing business and goals with GCI? |
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| Any other questions or comments? |
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| Where did you hear about GCI? |
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