Credit Application | Frederick Goldman, Inc.

Apply for open terms with Frederick Goldman, Inc. Before you start, have ready: • Your Federal Tax ID (EIN) • Your bank name and bank contact • At least five trade references For your security, do not enter Social Security numbers or full bank account numbers. Our Credit Department will contact you directly if they are needed. Your privacy: we use this information only to review your credit request and set up your account. It is kept confidential, is never sold, and is shared only with the bank and trade references you list. It is sent over an encrypted connection. Required fields are marked with an asterisk.

Section A. Legal Business Name*

DBA or Trade Name

Are you registered with the Jewelers Board of Trade?*

Yes

JBT Number (if registered)

Registered Business Address*

City*

State*

Zip*

Ship To Address (if different)

Ship To City

Ship To State

Ship To Zip

Business Phone*

Fax

Business Email*

Accounts Payable Contact*

Accounts Payable Email*

B2B Login: Full Name*

B2B Login: Title*

B2B Login: Email Address (used to sign in to the B2B site)*

Section B. Business Type*

Sole proprietorship

Partnership

Corporation

LLC

Federal Tax ID Number (EIN)*

State of Incorporation or Formation

Business Location Is*

Owned

Leased

Description of Business*

In Business Since*

At Address Above Since

Owner, Partner or Officer 1: Full Name*

Owner, Partner or Officer 1: Title*

Owner, Partner or Officer 1: Home Address*

Owner, Partner or Officer 1: Email*

Owner, Partner or Officer 1: Telephone*

Owner, Partner or Officer 2: Full Name

Owner, Partner or Officer 2: Title

Owner, Partner or Officer 2: Home Address

Owner, Partner or Officer 2: Email

Owner, Partner or Officer 2: Telephone

Owner, Partner or Officer 3: Full Name

Owner, Partner or Officer 3: Title

Owner, Partner or Officer 3: Home Address

Owner, Partner or Officer 3: Email

Owner, Partner or Officer 3: Telephone

Section C. Bank Name*

Bank Address

Bank City, State, Zip

Contact at Bank

Bank Contact Phone

Type of Account(s)

Checking

Savings

Money Market

Line of Credit

Account Number (last 4 digits only)

Type of Loan(s)

Loan Amount(s)

Collateral Securing Loan(s)

Additional Trade Reference 1: Company Name

Additional Trade Reference 1: Address

Additional Trade Reference 1: Telephone

Additional Trade Reference 2: Company Name

Additional Trade Reference 2: Address

Additional Trade Reference 2: Telephone

Additional Trade Reference 3: Company Name

Additional Trade Reference 3: Address

Additional Trade Reference 3: Telephone

Section E. Website URL

Facebook URL

Instagram Tag (@)

Other Social (specify)

Store Contact 1: Full Name

Store Contact 1: Role

Store Contact 1: Title

Store Contact 1: Telephone

Store Contact 1: Business Email

Store Contact 2: Full Name

Store Contact 2: Role

Store Contact 2: Title

Store Contact 2: Telephone

Store Contact 2: Business Email

Store Contact 3: Full Name

Store Contact 3: Role

Store Contact 3: Title

Store Contact 3: Telephone

Store Contact 3: Business Email

Terms and Conditions*

I affirm that the above information is true to the best of my knowledge, and I authorize Frederick Goldman, Inc. to make inquiries to the above references for the purpose of determining creditworthiness.

Anti Money Laundering. Is your company a member of LBMA, RJC or any similar international organization?*

Yes

Is your company CTPAT certified?*

Yes

Are you a "dealer" as defined by FinCEN (within the preceding year, both purchased and sold at least $50,000 of jewels, precious metals or precious stones)?*

Yes

Have you instituted an Anti Money Laundering program in accordance with the USA PATRIOT Act and applicable regulations?*

Yes

Has your company established a due diligence process to identify its business partners?*

Yes

Does your company have a process to identify each transaction and each supplier to your company?*

Yes

Has your company or senior management ever been charged with a violation of applicable anti bribery laws or regulations?*

Yes

Directors / Partners of the Company*

Owners of the Company (if different from above)

Section G. Electronic Signature: type your full legal name*

Signer Title*

Date Signed*

I am a proprietor, partner or corporate officer of the Applicant, and I certify that the information in this application, including the Anti Money Laundering data, is accurate.*

Retail Customer Credit Application