Amendment Confirmation Page

PLEASE COMPLETE AND SEND VIA EMAIL TO

CS@ALPARI-US.COM OR FAX TO +1 646.825.5761.

Alpari (US), LLC

14 Wall St., Suite 8B
New York, NY 10005
+1 646 825 5760
+1 646 825 5761
www.alpari-us.com

ACCOUNT INFORMATION

Glaucio Eduardo Bueno

Account Name: __________________________________________________________________________________
rua: apus 1034
Address: ________________________________________________________
Suite/Apt#: _____________________
Joinville
89226-732
Santa Catarina Zip/Postal Code: ________________
City: _____________________________
State/Province: ________________
+55 47 3473-1459
Brasil
Country: ________________________________
Telephone #: ___________________________________________
10.001.794-6
glauciobn@gmail.com
SSN/Tax ID/Passport #: _____________________________
Email: _______________________________________
Other Change: __________________________________________________________________________________
Reason for Amendment Request: ________________________________________________________________

THE ABOVE NAMED ACCOUNTHOLDER HEREBY REQUESTS AN AMENDMENT TO THE ACCOUNT

INFORMATION OF RECORD. BY SIGNING BELOW, THE ABOVE NAMED INDIVIDUAL IS AGREEING
TO THIS CHANGE AND CERTIFIES THAT THE INFORMATION PROVIDED IS TRUE AND ACCURATE.
THE EXECUTION OF THIS AMENDMENT DOES NOT ALTER OR OTHERWISE AMEND ANY
AGREEMENT BETWEEN ALPARI (US), LLC AND THE CUSTOMER. ALL OTHER TERMS AND
CONDITIONS OF THE FOREX CUSTOMER AGREEMENT, TOGETHER WITH ALL EXHIBITS AND
DISCLOSURE DOCUMENTS THERETO, SHALL REMAIN UNCHANGED AND IN FULL FORCE AND
EFFECT.

PRIMARY SIGNATURE
Glaucio Eduardo Bueno
Full Name (print): ___________________________________________________________________
Title (ex: trustee/authorized signer): ______________________________________________________
Signature: __________________________________________________________________________

27/09/2012
Date: ______________________________________________________________________________

SECONDARY SIGNATURE (if applicable)

Glaucio Eduardo Bueno
Full Name (print): ___________________________________________________________________
Title (ex: trustee/authorized signer): ______________________________________________________
Signature: __________________________________________________________________________

27/09/2012
Date: ______________________________________________________________________________
Copyright 2011 Alpari (US), LLC
Version 1.3

Alpari (US), LLC is dually registered with the CFTC as a Futures Commission
Merchant and Retail Foreign Exchange Dealer and is a member of the NFA.
NFA Member ID: 0379678

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