US Citizen doing business as an individual - Glines & Rhodes Precious Metal Refining

In accordance with the federally mandated USA PATRIOT Act, please fill out this form in its entirety and digitally sign at the bottom.

Employer's Name * Required
Date of Birth * Required
MM slash DD slash YYYY
Address 1 * Required
Address 2
Address 2 * Required
State * Required
Zip * Required
Phone * Required
Email
Length of Employment * Required
Social Security# * Required
Are you in compliance with the USA PATRIOT Act and its Anti-Money Laundering regulations, or are you exempt? *
Compliance * Required
- 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).
- Yes, 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).
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