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Customer Questionnaire
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 3
Name
*
First
Last
Phone
*
Year of Birth
*
Email
*
Occupation
*
Please Select One
Accountant
Actor/ Actress
Architect
Artist
Astronaut
Baker
Ballet Dancer
Bartender
Bellboy
Biologist
Boxer
Bus Driver
Businessman
Butcher
Cameraman
Caretaker
Carpenter
Cashier
Chef
Computer Programmer
Customs Officer
Delivery Man
Dentist
Diver
Doctor
Electrician
Engineer
Entrepreneur
Factory Worker
Farmer
Fireman
Fisherman
Flight Attendant
Florist
Gardener
Gas Station Attendant
Guitarist
Hairdresser
Judge
Lawyer
Librarian
Lifeguard
Manager
Miner
Model
Musician
Nurse
Office Worker
Optician
Paramedic
Pharmacist
Photographer
Pilot
Plumber
Police Officer
Politician
Priest
Real Estate Agent
Receptionist
Repairman
Scientist
Singer
Speaker
Student
Surgeon
Tailor
Taxi Driver
Teacher
Unemployeed
Veterinarian
Violinist
Waiter
How did you obtain your wallet? (barcode that you scan)
*
Someone sent/provided it to me
I created it
What platform/website did you use to create your wallet?
*
What is the purpose of your transaction?
*
Send Money
Investment
Buy Goods Online
Pay utility bill
IRS
US Marshall
Law Enforcement
Electric Bill
Do you plan on purchasing or sending more than $3,000 in a single day?
*
Yes
No
Next
Social Security Number (SSN)
*
Please describe the type of investment.
*
Are you or will you be sending money to someone else?
*
Yes
No
Please describe how you were contacted by the IRS.
*
Please describe how you were contacted by the US Marshall's.
Please describe how you were contacted by law enforcement.
Please describe how you were contacted to pay your utility bill/electric bill.
What is your relationship to the person who is receiving the cryptocurrency being purchased?
*
Significant Other
Fiance
Spouse
Friend
Relative
Other
What is his/her name?
*
First
Last
What country is the person receiving the bitcoin located in? (i.e. Nigeria, Italy)
*
Select One
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Côte d'Ivoire
Cabo Verde
Cambodia
Cameroon
Canada
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Congo-Brazzaville)
Costa Rica
Croatia
Cuba
Cyprus
Czechia (Czech Republic)
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (fmr.
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Holy See
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar (formerly Burma)
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
North Korea
North Macedonia
Norway
Oman
Pakistan
Palau
Palestine State
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Sweden
Switzerland
Syria
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Other
What is the family relationship? (e.x. aunt, cousin)
*
How long have you known them?
*
How did you meet?
*
Have you met face to face? (In Person)
Yes
No
When was the last time you saw each other?
*
What is the total amount of money you plan on sending to this person?
*
Please describe the purpose of the funds:
*
Next
What is the source of funds being used to purchase the cryptocurrency?
*
Personal Savings / Income / Salary
You Received a Wire Transfer from Friend/Spouse/Other
You Received a Check From Friend/Spouse/Other
You Received Cash
What is your expected monthly volume of purchases to this wallet?
*
$0 - $2,999
$3,000 - $9,999
$10,000 - $49,999
$50,000+
Consent
*
I agree to the terms of service and privacy policy
Phone
Submit
