Introducing Broker Details

Are you an individual or company？*

Company

Insert company name:*

Country of Incorporation:*

Individual

Title:*

First Name:*

Middle Name (if you have any):

Last Name:*

Date of Birth:*

Address Line 1*

Address Line 2

City*

State/Territory/County:

Postcode*

Country of Residence:*

Nationality (as it appears on your Passport):

Phone Code*

Phone Number*

E-mail:*

First Name (Contact Person):*

Last Name (Contact Person):*

Address Line 1:*

Address Line 2:

City:

ADDITIONAL QUESTIONS

Skype ID

Are you an affiliate with any other brokers?*

How long have you been working as a FOREX affiliate?*

Which country will you operate your Affiliate program from？*

Which country/region will you refer clients from?*

How many clients do you intend to refer to us?*

Trading volumes (in lots) expected monthly？*

Average deposit size expected?*

Do you offer any services to clients？*

Type of service:*

Type of service: Other - please specify*

Do you hold a Financial Services Licence or Authorisation？*

Name of the regulatory body:*

Licence number:*

Name of the regulatory body: Other - please specify*

Are you working with other providers？*

How will you refer clients？*

How will you refer clients？ Other - please specify*

Do you have a website？*

Do you have a website？ Yes - please specify*

How often do you communicate with potential clients？*

How do you communicate?*

How do you communicate? Other - please specify*

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Phone

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