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Title (Mr,Ms,Dr,etc.)
Name
Company
Street Address
City
State
Zip Code
Telephone
E-mail Address
Select One	Individual Investor Professional Advisor
Do you use a financial advisor?	Yes No
If yes, which one?
How did you first hear about us?	-- Choose One --InternetLink ExchangeBrokerage firmAnalytical serviceNewspaper/magazine articleSeminarRadioPrior knowledge of Kevin WenckOther
Select Account Type	Regular IRA ROTH IRA

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Polynous Capital Management, Inc.
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