BlinkTrade - Broker Application Form [ www.blinktrade.com ]

YOUR FINANCES
Do you have a home in your name?*

Yes - Mortgage fully paidYes - Mortgage more than 50% paidYes - Mortgage less than 50% paidNo
Net worth*
In US$ as of 12/31/2013
Bitcoin net worth *
in bitcoins as of today

YOUR KNOWLEDGE OF THE MARKET
Do you currently own a bitcoin exchange/brokerage?*

YesNo
If yes, please give the url
What are your initial expectations of being a broker at BlinkTrade?
ex: how much money do you expect to earn on brokerage fees?
How many bitcoin users are in your region/state/country?
Give a rough estimate

PERSONAL REFERENCES
You can either give us your current/previous employers or recent business partners as references
Name

First NameLast Name
City, State
Phone

Area CodePhone Number
Briefly describe your relationship with this person
Second reference
Name

First NameLast Name
City, State
Phone

Area CodePhone Number
Briefly describe your relationship with this person
Third reference
Name

First NameLast Name
City, State
Phone

Area CodePhone Number
Briefly describe your relationship with this person