Ohio Precious Metals, LLC

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US PATRIOT ACT/AML   Please enter the information below and click the Submit Form button. After you confirm the information on the next page, please sign and fax the form. Know Your Customer - KYC *Requestor's First Name Requestor's Middle Name *Requestor's Last Name Prospective Customer Full Legal Name (if different than Requestor's Name) *Customer Street Address (PO Box is NOT Acceptable) Address Two *City *State Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *Zip *Country Has the Company moved in the last 5 years? Yes    No If yes, please provide previous address Customer Street Address (PO Box is NOT Acceptable) Address Two City State Zip Country Telephone Fax Email Web Site Do you have an AML Program in place? Yes    No If no, please indicate if you are exempt from compliance and the exemption. Exempt? Tax ID If Customer does not have a Tax ID, please explain Import/export goods to/from the United States? Yes    No If yes, please provide a list of countries Countries Estimated Dollar Amount Per Shipment $ Estimated Number of Shipments Per Month 0-5    6-10    11+ Is Company Publicly Traded? Yes    No If yes, please provide the name of the exchange. Exchange CEO, Full Name CFO, Full Name Number of Employees 1-100    101-1000    1001-5000    5000+ Has the company been established for more than 3 years? Yes    No If established for LESS THAN 3 years, please provide the year established Year Established Is company regulated? Yes    No If yes, please provide primary reporting regulator or supervisory body Regulator Company Type Head Office/Holding Company    Subsidiary If Subsidiary, please provide name of Head Office/Holding Company Head Office/Holding Company Describe the source of metal for refining Banking Information Where accounts are held, address, telephone number, name of account officer Trade References Trade Reference 1 Company Name Contact Name Contact Phone Number Trade Reference 2 Company Name Contact Name Contact Phone Number Trade Reference 3 Company Name Contact Name Contact Phone Number

Ohio Precious Metals, LLC 16064 Beaver Pike Jackson, OH 45640	opm@opm-llc.com 740.286.6457 fax 740.286.2072
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