Bitcoin & Crypto Kiosk

In order to continue using BitcoinNW, we need to gather a little more information from you about the nature of your transactions. Please note that we may need to contact you for clarification or additional details.

Please complete the form below

Phone Number

Please use the phone number that you used to register with at the machine.

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Full Name

Citizenship

Are you a US citizen, a non-resident alien, or foreign national?

Where did you learn about bitcoin?

What is your purpose for buying/selling bitcoin?

Wallet

Do you and only you own and control the cryptocurrency wallet you are using?

If you are purchasing bitcoin, where are the funds coming from?

Is there a specific amount of bitcoin you need to buy or sell over time? If so, how much, and why?

Has someone asked you to register, buy, and/or sell on their behalf?

Occupation

What is your occupation?

Funds

What is the source of funds for your Bitcoin purchases?

Customer Questionaire

Please complete the form below