Legal Name:

Company Name (dba) if different::

Business Address:

City: State: Zip Code:

Phone number: Fax number:

Email Address:  

Website Address:

Tax ID/EIN or Social Security Number:   

Resale Certificate Number:

Name of Owners:

Name of Gemstone Buyer(s) (if different):

Have you or will you establish an AML Program, in accordance to the USA Patriot Act?

Yes   --- No

Your response to this inquiry is an important element in our compliance program. Your prompt attention to this matter is greatly appreciated. All information will be kept confidential.