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#Launch100 Program Registration
Sign up to #Launch100 in order to get your account funded
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1
Full Name
*
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First Name
Last Name
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2
Phone Number
*
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Area Code
Phone Number
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3
E-mail
example@example.com
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4
How did you hear about us?
*
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Newspaper
Internet
Social media
Other (Please specify...)
Newspaper
Internet
Social media
Other (Please specify...)
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5
Other
*
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6
Feedback about us:
Please provide feedback to better your experience
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7
Have you used Bitcoin before?
Yes
No
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8
If Yes, please submit a screenshot of your bitcoin wallet/exchange deposit address back office
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9
Suggestions if any for further improvement:
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10
Will you be willing to recommend us?
Inviting your friends to take part will include them in the lucky $200 draw & they too may potentially earn $10 in bitcoin
Yes
Maybe
No
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11
Please give reference of any two people whom you feel:
Full Name
Email
Contact Number
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
1
2
Full Name
Row 0, Column 0
Email
Row 0, Column 1
Contact Number
Row 0, Column 2
Full Name
Row 1, Column 0
Email
Row 1, Column 1
Contact Number
Row 1, Column 2
1
of 2
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12
Number of years you have known about bitcoin & cryptocurrency
Years
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13
Type of industry currently involved in
Start up (SMME)
eCommerce & Retail
Education & eLearning
Media & Entertainment
Developing Brand
Start up (SMME)
eCommerce & Retail
Education & eLearning
Media & Entertainment
Developing Brand
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14
Please verify that you are human
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