COIMx Private Sale Application Form

COIMx Private Sale Application Form

Note: Please complete all sections below. Incomplete forms may result in delays or disqualification. All personal information will be kept confidential and used solely for compliance and project-related communications.
Full Name*

First NameLast Name
Birth Date

MonthDayYear
E-mail*
Country of Residence*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code(For legal compliance reasons)
ID Verification*

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A valid government-issued ID (passport, driver’s license, or national ID). Cancelof
Preferred Payment Crypto Method*
Intended Investment Amount*
Please specify in USD
Receiving Wallet Address for COIMx*
Provide the ERC-20
Should be Empty: