Coinhub ATM Registration Form

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Name*

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Phone Number*

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Are you a US citizen, Non-Resident Alien, or Foreign National?*

If you answered "Other", please explain.*

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Are you, or anyone in your immediate family, a senior foreign political figure, either in a foreign country or the US. If so, please explain.*

Are you, or anyone in your immediate family, a senior foreign political figure, either in a foreign country or the US?*

Please explain how you or someone in your family is a political figure.*

Source of Funds / Occupation (Please include your occupation such as your current or past employer as well as your position or other information)*

Are you involved in any of the following Industries?*

If you answered Yes above, please explain your involvement in the industry or industries you selected.*

Reason for Buying / Selling Bitcoin*

Please check all of the boxes if you confirm that you are only purchasing cryptocurrency for yourself and to a wallet you control and have access to:*

I confirm that I am only purchasing Bitcoin for my own self and not for anyone else or to send to anyone else for the purchase

I confirm that I am not sending Bitcoin to a wallet that someone sent to me over the phone or email

I confirm that I am not paying any proclaimed "IRS" or any other Federal / government agency (as they will never ask or accept Bitcoin payment)

I confirm that I am not sending Bitcoin to a foreign boyfriend / girlfriend I met online (or any individual you do not know in person). I am only entering my own Bitcoin wallet that I solely own, control, and have complete access to

I confirm that I am not buying Bitcoin to fix a virus or ransomware on my computer

I confirm that I understand that my Bitcoin purchase is non-refundable as Bitcoin transactions are irriversible once Bitcoin is sent and that Coinhub sends Bitcoin to the wallet address I provide which I confirm is my own

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