INVESTOR INQUIRY – Dyversify

Full Legal Name

Date of Birth

Phone Number

Address

Street Address

City

State

Country

Are you investing as:

Individual

Joint Account

Entity

Do you currently have an account with Interactive Brokers or another Futures Commission Merchant?

Yes

Broker Name:

Preferred Method of Contact:

Phone

Scheduled Call

I consent to being contacted regarding CTA managed account services.

By submitting this form, I certify that the information provided is true and accurate to the best of my knowledge.

Signature

Sign Here

CTA INVESTOR INQUIRY FORM