Open An Account

1. Business Information

Company Name *

Street Address *

Suite / Room #

City *

State *

Zip *

Phone *

Fax

Ship Address (if different)

Ship City

Ship State

Ship Zip

Date

E-mail Address *

Additional E-mail Address(es)

Business Established (year)

Tax ID # *

Please check one

IndividualPartnershipCorporation

Do you currently operate under any other names?

YesNo

If yes, please list

Owner *

Owner's Address

Owner's City, State, Zip

Owner's Cell #

SS # (Social Security Number)

D.O.B. (mm/dd/yyyy)

Member of the N.Y. DDC?

YesNo

DDC Member #

Member of the JBT?

YesNo

JBT Member #

Web address

Key Employees

Diamond Buyer(s)

Manager

Asst. Manager

Bookkeeper

Messenger

2. Industry References

Please list five (5) industry references (companies you currently do business with).

Reference 1

Company Name

Contact Person

Address

Phone

E-mail

Reference 2

Company Name

Contact Person

Address

Phone

E-mail

Reference 3

Company Name

Contact Person

Address

Phone

E-mail

Reference 4

Company Name

Contact Person

Address

Phone

E-mail

Reference 5

Company Name

Contact Person

Address

Phone

E-mail

3. AML: Request for Company Information Under the USA PATRIOT ACT

The Diamond Feed fully complies with its legal obligations under the USA PATRIOT ACT and BANK SECRECY ACT and any relevant regulatory requirements. In order to complete our compliance obligation, we are required under our policy and program to acquire the following identifying information.

Resale Certificate Number

Name of Owners

Number of Employees

Does your company implement an anti-money laundering program?

YesNo

If no, will your company implement an anti-money laundering program?

YesNo

I hereby certify that the above information is correct:

Signature (type your full name) *

Date

Please Print Name

Title

4. Bank Information

Name of Bank

Account #

Phone #

Contact Person

Address

City

State

Zip

5. Insurance Information

Insured By

Contact Name

Type & Amount of Coverage

Tel #

I hereby authorize the release of any information to The Diamond Feed LLC. from the above named references for the purpose of establishing a credit account. I hereby personally guarantee the obligation of the above applicant. I further agree that the personal guarantee will not be affected by any bankruptcy or insolvency proceeding. As a further inducement to extend credit I/we agree that in the event suit is brought on any obligation hereafter owed by me/us to you that I/We will pay (1) reasonable attorney's fees and necessary collection costs incurred by you in collecting the said obligation, and (2) collection agency costs or collection costs even if suit is not instituted.

Name *

Authorized Signature (type your full name) *

Date *

Title (owner only)

I have read and agree to the above authorization and certification.