General Inquiry Contact Form

Broker Fraudulent Activity Request Form
To file a complaint with the Broker Control Association, you must fill in your personal data. By submitting the form below you automatically consent to the processing of personal data, which is confidential.
Authorized Signer*

First NameLast Name
Country*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Information about broker
Name of broker*
Amount of loss of personal funds*
Amount of lost earnings*
Amount that was able to withdraw from the broker*
Whether you contact us on your own or through the services of an intermediary. Please specify the name of the company and the name of the specialist with whom you cooperate.
Signature*

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I confirm that the information I wrote above is true.*

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Broker Fraudulent Activity Request Form