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351IDENTIFICATION AND VERIFICATION FORM(TO COMPLY WITH THE USA PATRIOT ACT)In order to complete our compliance obligation, we are required under our policy and program to acquire the following identifying information for ALL our business partners and customers. Please provide the following identifying information.You may complete this form and fax it back to the following number: (513) 642-2449 or email to newaccounts@qgold.com.Registered Legal Name: Trade Name (if different): Registered Legal Address: Business Address (if different): Postal Address (if different): Telephone Number: Fax Number: E-Mail Address: Website Address: Directors of the Company: Owners of the Company (if different): Federal Tax ID Number: Resale Certificate Number: Government License Number: YOU MUST CHOOSE ONE OF THE FOLLOWING: YES - We have or will be instituting an AML Program. { Retailers must institute an AML program if they (A) Have a Foreign supplier, (B) Purchase precious metals or stones from the public, (C) Purchase from Government auctions, or (D) Purchase from Estate sales. } NO - We will not institute an AML Program due to our status as an %u201cexempt%u201d retailer or other industry. { A retailer is exempt from AML if they only purchase from U.S. Suppliers who are AML compliant. } Signature of person filling out form Title DateBy signing, I confirm that the above details are true and correct.DETACHABLE PAGEFor additional information regarding the Patriot Act, go to www.jvclegal.org. Or call (212) 997-2002