full Name*
address
Phone*
Email Address*
Facebook Profile
Instagram Profile
LinkedIn profile
Twitter profile
Website
WILL YOU HAVE A POWER OF ATTORNEY OVER ACCOUNTS INTRODUCED?
Yes
No
Will you be actively assisting accounts on a day to day basis? 
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WILL YOU PROVIDE any ADVISORY SERVICES TO ACCOUNTS?
Yes
No
WILL YOU PERFORM DISCRETIONARY TRADING ON BEHALF OF CLIENTS?
Yes
No
WILL YOU PROVIDE ANY OTHER SERVICES TO THE CLIENTS?
Yes
No
DO YOU CURRENTLY ACT AS AN INTRODUCER WITH OTHER COMPANIES?
Yes
No
Do you have an office?
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Current number of clients
Territories in which clients are located?
Channels used to attract new business:
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WERE YOU SUBJECT OF ANY DISCIPLINARY PROCEEDINGS OF ANY EXCHANGE, REGULATORY AUTHORITY, GOVERNMENT BODY OR AGENCY, OR IS IT AWARE THAT SUCH PROCEEDINGS ARE PENDING?
Yes
No
Geomatrix Limited will only enter into a Country Representative Agreement, or similar arrangement with you if it considers such an arrangement suitable. To determine suitability, 4XC will rely on the information that you provide in this form. 
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