Credit Application Form

Company Name *

Trade Name (D/B/A)

E-Mail*

Phone*

Fax

Adress*

City*

State*

Zip Code

ID Number

JBT Listed/Rated

Ship To (if different) Name:

E-Mail

Phone

Fax

Adress

City

State

Zip

Salesman

Type of Organization *

Corporation
Partnership
Individual Owner

Type of Business *

Wholesaler
Chain
Flyer
Manufacturer
Department Store
Independent Jeweler

Name Of A/P Contact

Title

Name Of Contact

Name

Title

Name Of Buyer

NAME OF INSTITUTION*

CITY/STATE*

ACCOUNT*

PHONE

FAX*

BANK OFFICER/CONTACT

NAME

CITY/STATE

PHONE

FAX

PERSON TO CONTACT

NAME

CITY/STATE

PHONE

FAX

PERSON TO CONTACT

NAME

CITY/STATE

PHONE

FAX

PERSON TO CONTACT

NAME

CITY/STATE

PHONE

FAX

PERSON TO CONTACT

"YOU HAVE AUTHORIZATION TO VERIFY THE ABOVE INFORMATION VERBALLY OR IN WRITING
GUARANTEE IN ORDER TO INDUCE MIDAS CHAIN INC. TO SEL MERCHANDEE AND EXTEND CREDIT TO YOUR COMPANY THE UNDERSIGNED PERSNOALLY GUARANTEES THE PROMPT PAYMENT OF ANY, AND ALL INDEBTNESS WHICH MAY INCURRED BY THE APPLICANT TO MIDAS CHAIN INC.AND THE EVENT OF ANY DEFAULT AT ANY TIME BY THE APPLICANT, MIDAS CHAIN INC. SHALL BE ENTITLED TO LOOK TO THE INDERSIGNED GUARANTOR (S) IMMEDIATELY FOR SUCH PAYMENT WITHOUT PRIOR DEMAND OR NOTICE

IN THE EVENT THIS ACCOUNT MUST BE REFERRED TO AN ATTORNEY OR AGENCY FOR COLLECTION ANY INDEBTNESS OWED BY GUARANTOR OR THE APPLICANT TO MIDAS CHAIN INC. THE GUARANTOR AGREES TO PAY REASONABLE COSTS THEREOF INCLUDING COLLECTION FEES, REASONABLE ATTORNEY FEES, COURT AND EXCPENSES INDURRED IN CONNECTION THEREWITH"

DATE*

SIGNATURE*

Dear Business Partner,
I am writing to you to inquire whether you have instituted an anti-money laundering (AML) program in compliance with the USA Patriot Act, the US Bank Secrecy Act and other regulatory requirements.
In order to complete our compliance obligation, we are required under our policy and program to acquire the following identifying information for all our business partners and customers. Please provide the following identifying information. You may complete this form and fax it to 201-244-1151 or scan and email it to carol@midaschain.com.

COMPANY NAME

OWNER NAME

ADDRESS

TELEPHONE

FAX

TAX ID

RESALE

I confirm that the above details are true and correct.

SIGNATURE

DATE

PRINT NAME

Your response to this inquiry is an important element in our compliance program. Your prompt response to this is greatly appreciated.
Sincerely,
Sam Samuel

CONFIDENTIAL CREDIT APPLICATION

Type of Organization *

Type of Business *

Name of Principal(s) or Owner(s)

Bank Reference

Trade Reference

Resale Certificate#/Tax Exempt

AML Form