AML Program Company- Midstates Recycling & Refining, Inc.

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Company - Customer Information Sheet

General Information
Company Name
Contact Name
Address
City
State	Zip
Telephone	- - Fax - -
E-Mail Address
Website Address
Previous Address If Moved In Last Five Years
Company Information
Type Of Company	Proprietorship LLC Corporation
	Year Established State
Federal ID #
State Resale Tax ID #	(Please provide copy)
Names Of Key Officers	D.O.B / / D.O.B / /
Type Of Business	Other
Does your company import or export goods to / from outside the United States?	Yes No
Does your company have an Anti-Money Laundering Program in place?	Yes, our compliance officer is: No
Parent Company Information (Skip if N/A)
Name Of Parent Company
City	State
Bank Information
Bank Name
Address
City
State	Zip
Telephone	- - Account #
Bank Contact
Trade Associations
Please choose any associations you are a member of. (Ctrl + Click to select multiple)	Others
Sales Representative
If you spoke to a Mid-States sales representative please select them here.

Required

(800) 551-0083 Toll Free - (847) 298-0010 Local
REFINER AND SUPPLIER OF PRECIOUS METALS TO TRADE ONLY.