Anti-Money Laundering Campaign Form for Individuals

Customer Information Instructions

Advanced United Refining Inc. is required by law, by corporate policy, and by good business practice to identify and know our customers, and to ensure that our transactions with them meet high standards of integrity. Accordingly we require customers to provide the following information and certification, as a condition to doing business.

The following Customer Identification Form seeks basic information that identifies a customer, and that permits Advanced United Refining Inc. to verify that information, to check with third parties, and to make contractual commitments. Advanced United Refining Inc. requires that all applicable information requested in this form be provided.

For each natural person who is identified as a customer, Advanced United Refining Inc. requires a copy of a current government-issued photo identity document, such as a passport or driver’s license. This document must show the issuing government, document number, dates of issue and expiration, date of birth and signature of the individual, and a clear photograph.

Anti-Money Laundering Campaign Form (Individuals)

SECURITY NOTICE: Your privacy is important to us at Advanced United Refining Inc. Your information is protected by 128-bit SSL encryption for enhanced security during submission.

"*" indicates required fields

First Name*

Middle Name

Last Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number and Extension*

Fax

Email Address*

Government Issued Photo Identification Number*

Attach a File*

Max. file size: 10 MB.

Upload a copy of a current government-issued photo identity document, such as a passport or driver’s license. This document must show the issuing government, document number, dates of issue and expiration, date of birth and signature of the individual, and a clear photograph.

Social Security Number

Citizenship*

Previous Address

Enter your previous address if you have moved within the last three years.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Description of Transaction with Advanced United Refining Inc.*

Please give us a brief description of your transaction with us (i.e., sale of inheritance, sale of investments, refining of production scrap, etc.)

Source of Material and History*

Please describe the source of the material you have for refining and brief explanation of how it was obtained.

How did you obtain this material?*

Bank/Financial Institution Information

Bank/Financial Institution Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

Agree to Terms

By checking this box, I warranty to Advanced United Refining Inc. that any products or materials I submit for smelting, refining and purchase is with good legal title.*

Yes, I agree to the terms above.

YOU MUST AGREE TO THE TERMS TO PROCEED.

Signature*

Please type your name

Date*

Email*

Please re-enter your email address

IMPORTANT

You will be sent a copy of this completed form for your records by email after submission.

SECURITY NOTICE: Your information is protected by 128-bit SSL encryption for enhanced security during submission.