Open Account US Citizens Doing Business as an Individual

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US Citizen Doing Business as an Individual NEW CLIENT and USA PATRIOT Act Compliance Form

In accordance with the federally mandated USA PATRIOT Act, please fill out the below applicable section in its entirety and sign the bottom of the form.

I. US Domestic or Foreign Company

III. Non-US Citizen Doing Business as an Individual

II. US Citizens Doing Business as an Individual
First name*	Last name*
Email*	Telephone
Fax
Date of Birth	Social security #
Home Address 1	Home Address 2
Home City	Home State*
Home Zip Code
Country*	Other Country
Employers Name
Employers Address 1	Employers Address 2
Employers City	Employers State*

Employers Zip code

Employers Country

Length of Employment

Are you in compliance with the USA PATRIOT Act and its Anti-Money Laundering regulations, or are you exempt?

Yes, we are in compliance with the PATRIOT Act as it concerns our industry (we have implemented an anti-money laundering program).
No, we are not in compliance with the PATRIOT Act as it concerns our industry (we have not implemented an anti-money laundering program).
We are exempt from the PATRIOT Act as far as it concerns our industry (we do not deal in more than $50,000 worth of covered goods (jewels, precious metals, etc). annually).

Are you in compliance ?

Scrap Material Details

What form is your scrap in? (For Ex. Oily cuttings, jewelry, grindings, sweeps, filters, etc).

How much volume do you have?

What is the origin of your scrap (for Ex. Mfg. waste, obsolete inventory, trading)?

Please provide any further details of this scrap or future scrap opportunities:

Digitally Sign Here

Signature*

Customer Name (Type)

Title

Open Account US Citizens Doing Business as an Individual

Glines & Rhodes, Inc.