What is the name of the corporate entity you will be filing your membership application under?: *

Where is the corporate head quarters for the company located?: *

What is the official web site of your company?: *

Who are the major principals and owners of the corporation? (Anyone who is more than a 10% owner):

Is the firm currently licensed or regulated in any jurisdiction?: YesNo

If Yes, please provide the regulator and license number:

How many years has your company been in business as a financial services provider?:

What markets is your company currently operating in?:

What languages does your company support?:

Which trading platforms does your company offer your customers?:

Which financial trading products does your company currently offer to your clients?:

What is the minimum account size available to trade with your company?:

What price vendors are used to determine settlement price?:

Does the firm cover all or part of its positions? If yes, please list the name of counter-parties:

Does the firm outsource their dealing desk?: YesNo

Does your company store tick data?: YesNo

If yes, please specify for how long:

How many complaints do you estimate would be handled by the Financial Commission per month coming from your company?:

Has your company ever had any previous disciplinary actions from a regulator or legal entity?: YesNo

If Yes, please specify all instances of legal or regulatory disciplinary actions:

Name:

Position Held with the company:

Direct Phone Number:

Email Address:

Name: *

Date: *

Position Held with Company: *

Signature: