Dealer Application

Fields marked with * are required.

Legal Business Name*Doing Business As (DBA)Date of FormationCountry of Origin*Company Phone Number*Primary Email*Company WebsiteState Sales Tax NumberEIN / SSN*EIN / SSN Number*

Business Street Address*Address Line 2 (Floor, Suite, etc.)City*State*Zip*

Shipping address is the same as business address

References

Provide up to five trade references.

Reference 1 — CompanyContact NameContact Phone

Reference 2 — CompanyContact NameContact Phone

Compliance

We ask that Lipton dealer network members affirm they are in compliance with the USA Patriot Act, the Bank Secrecy Act and all Anti-Money Laundering laws.

Choose the option that best describes your business*Choose one.

A) We have a written anti-money laundering policy and program in place that is compliant with the USA Patriot Act and Bank Secrecy Act and operate in compliance with it.B) We are not a 'dealer in precious metals, stones and jewels' as described by the USA Patriot Act.C) We are exempt from compliance from the USA Patriot Act.

I certify that all information given here is true and accurate.