XTROPTIONS.GOLD Re-Balance Request Form
Email address *
First Name *
Last Name *
Current mailing address *
City *
State *
Zip *
Country *
Phone number *
Quantity of XTROPTIONS.GOLD to be Re-Balanced *
Please enter your wallet ID *
Approximate date wallet was created? *
MM
/
DD
/
YYYY
Who referred you? *
Referral ID ( If applicable)
Please Attach a PDF or JPG of a current Government issued photo ID * *
Required
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