BurstIQ Signature Bounty Registration Form

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Bounty Allocation: 30% of total bounty program

Activities & Stakes:
- Legendary/Hero: 6 stakes per post
- Sr. Member: 4 stakes per post
- Full Member: 3 stakes per post
- Member: 2 stakes per post
- Jr. Member: 1 stake per post

How to Participate:
- Fill out this form
- Check to make sure you are listed in this table: https://goo.gl/gsyws2
- Change your signature, avatar and/or text (in accordance with your rank)

Restrictions:
- Only go-forward posts will be counted, not previous posts (based on the time that you complete the form)
- The signature must be kept until the end of the crowdsale
- Substantially negative posts will disqualify you from participation

Answers provided below will be independently verified. If answers provided below are found to be substantially different from the independent verification, you will be disqualified from the program.

Bitcointalk Username *

Bitcointalk Profile Link *

Forum Rank *

Bitcointalk posts count *

E-mail *

ETH address for receiving bounty *

IMPORTANT: You must use an ERC20 compatible ETH address (such as MyEtherWallet, Parity, Mist, etc.). Do not submit ANY non-ERC20 Exchange address - if you do, your tokens will be lost and we will not resend them.

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