800.343.1196

Contact Information:

189 East Street
Attleboro, MA 02703

Office Hours: M-F 8-4:45 PM EST

Tel: 508-226-2000
Toll Free: 800-343-1196
Fax: 508-226-7136

Email: sales@glinesandrhodes.com

Open Account Non-US Citizen Doing Business as an Individual

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Non-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

II. US Citizens Doing Business as an Individual

III. Non-US Citizen Doing Business as an Individual

First name*
Last name*
Email*
Telephone
Fax
Passport # (please attach copy of passport)
Passport Image
Country of issuance
Date of Birth
Social security # or foreign equivalent
Title
Home Address 1
Home Address 2
Home City
State / Province
Home Zip Code
Country*
Other Country

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 type of Precious Metals are you looking to refine?
Gold
Silver
Platinum
Palladium
Iridium
Ruthenium
Rhodium
Other (Please list):
Are any of these deleterious elements present?
As-Arsenic
Be-Beryllium
Bi-Bismuth
Cd-Cadmium
Hg-Mercury
Ni-Nickel
Pb-Lead
Sb-Antimony
Se-Selenium
Sn-Tin
Te-Tellurium
List any other known metals or materials present:
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