Noble AML Online Form

The undersigned hereby certifies to with all applicable federal, state, and local holding and reporting requirements with respect to the purchase and resale of precious metals [Noble Metal Refining (NMR)] that it is compliant with regulations of the USA Patriot Act of 2001, the Bank Secrecy Act (BSA) with respect to the operation of its business and sale to NMR.

The undersigned further certifies that it complies with applicable Anti-Money Laundering (AML) laws and regulations, including a written Anti-Money Laundering Program, which complies with Anti-Money Laundering (AML) laws and regulations.

Business Name:*
Type of Organization:*
- Corporation
- Partnership
- LLC
- Sole Proprietor
Address:*
Street Address Address Line 2 City State ZIP Code
Business Phone:*
Business Email:*
Federal EIN:*
State of Incorporation:*
Years in Business:*
The undersigned represents and warrants that (a) none of the precious metal provided to NMR will originate from, relate to, further, or be involved or derived in any way from any type of activity that is criminal, illegal, illicit, or otherwise prohibited; (b) Client has complied with all applicable federal, state and local holding and reporting requirements with respect to the purchase and resale of precious metals; and (c) that all information is true and accurate. The undersigned provides this certification to NMR under penalty of perjury and acknowledges that NMR and its agents shall rely on the information contained herein in connection with the purchase by NMR from the undersigned.
Signature*
Type Name of Signature:*
Date*
MM slash DD slash YYYY

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