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Patriot Act Compliance

As of January 1, 2006, diamond wholesalers are being required to have information on all customers in compliance with the Patriot Act. None of this information will be used by Crown Diamond unless requested by the Federal Government. This form is being managed and maintained by our Compliance Officer as required by the Patriot Act.

First Name:*
Last Name:*
Registered Company Name:*
Trading Company Name:*
(DBA if applicable
Address:*
City, State, Zip Code:*
Telephone:*

Please enter number as 123-456-7890
FAX:*

Please enter number as 123-456-7890
E-mail:*

Website:

Tax ID Number:

Bank:*

Directors of Company:*

By selecting submit I am confirming that the above information is accurate and understand that this information is required by Federal Law and compliance with the Patriot Act. If this information should change I will contact Crown Diamond and update the information.

14 Piedmont Center Suite 417 Atlanta, GA 30305 USA
(404)266-2818 — (800)347-1189 — 888-CROWNDIamond
FAX: (404)264-9524

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