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It's The Law!

Dear Valued Customer,

As part of the implementation of the U.S.Patriot Act, the U.S. Tresury Deparment has issued an interim final rule requiring "Dealers in precious metals, precious stones, jewels and covered goods" to implement an anti-money laundering program.

Our company is operating in full compliance with the U.S. Patriot Act's Anti-Money Laundering Program. In order to fulfill our obligation in the instance of a FinCen(Financial Crimes Enforcement Network) audit, we need to have a record of pertinent business information on the companies whom we deal with.

As such, we respectfully request that you complete the information on the accompanying form and return it to us either by mail or fax using the contact information on the bottom. Please be assured that all the information that you provide will remain completely confidential.

As in the past, we will continue to conduct our business operations with the utmost integrity. We thank you in advance for your prompt attention to this matter and we look forward to continuing our business relationship.

CREDIT APPLICATION FORM

 Please enter the information below.( * Required fields)
*Legal Business Name:
*D/B/A if Applicable:
*Company Address:
*City:
*State:   *Zip Code:
*Are you a member of any organization?   Yes:    No: 
*If so, please name them:    
*Company Phone Number:   
(Including Area Code)
*Company Fax Number:  
(Including Area Code)
*Company Email:
*Company Website:
*Federal Tax ID Number:
*Social Security Number:
*Year Company Established:
*Name of Owners/Principals: 
Bank Reference
*Bank Reference/ Bank Name:
*Bank Address:
*City:
*State:   *Zip Code:
*Primary Contact:
*Phone Number:

*Is this company AML (Anti-Money-Laundering) compliant pursuant to the USA Patriot Act?
Yes:   No:  If No,Why?

I certify that the above information is true and correct and I am willing to provide any neccessary documentation
to confirm the above upon request.
*Print Name:     *Title:  
*Signature:   *Date:  
* Trade Reference
*Company Name: 
Please provide at least (3) Trade References (Give only names of those you buy from on an open account)
1. *Trade Name: *Contact Name: 
*Address: 
*Phone Number: *Fax Number: 
2. *Trade Name: *Contact Name: 
*Address: 
*Phone Number: *Fax Number: 
3. *Trade Name: *Contact Name: 
*Address: 
*Phone Number: *Fax Number: 
4. Trade Name: Contact Name: 
Address: 
Phone Number: Fax Number: 
5. Trade Name: Contact Name: 
Address: 
Phone Number: Fax Number: 

Clear




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