6222 Richmond Ave Suite 690 Houston, TX 77057
Fax: 713-975-8463 Off: 713-850-8570
Email: [email protected] Website:


We have instituted an anti-money laundering (AML) program in compliance with the USA PATRIOT Act, the U.S. Bank Secrecy act and other regulatory requirements.

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.

Section A - Applicant

Legal Business Name (including trade names and DBAs): (“Applicant”)
City: State: Zip:

Section B - Business Information

Accounts Payable Contact Person: Telephone: Fax:
E-mail: Address:
City: State: Zip:
Description of Business:
Date Established: Business Location: Owned Leased (Landlord: )
Type of Entity: Sole Proprietor Partnership Corporation Other:

The Applicant agrees to inform Creditor of any change in entity status.

State of Incorporation/Formation: Year of Incorporation/Formation:
Federal Tax Identification Number: Estimated Annual Sales:
Amount of Credit Requested: Sales Tax Exemption Certificate: No Yes (if Yes, attach copy of signed certificate).
Owners/Partners/Members/Directors* Title: Home Address: Telephone: Social Security Number:

Section C - Banking Information

Bank: Contact Person at Bank: Telephone:
Address: City: State: Zip:
Type of Account(s): Account Number(s): Type of Loan(s); Amount(s): Collateral Securing Loan(s):

Applicant hereby authorizes the Bank Contact listed above to release all information requested. It is understood that all information will be kept confidential.

Section D – Trade References

Applicant hereby authorizes Creditor to contact trade references (including those listed below) and any credit reporting agencies to obtain credit information.

Reference Name, Contact: * Address: Telephone:

* Attach additional pages if necessary.

Section E - Financial Statements

Attached to this credit application is the most recent financial statement of the Applicant. The Applicant agrees to provide to Creditor updated financial information upon request, and to timely provide an annual financial statement to creditor as a condition of the continuation of this credit.

Has Applicant ever (i) filed for bankruptcy, (ii) been involved in an involuntary bankruptcy proceeding, (iii) an assignment for the benefit of creditors or (iv) a composition agreement?

No Yes
(if yes, explain: )

Section F - Miscellaneous

  1. Applicant acknowledges that this credit application is for the extension of credit for business purposes only and not for the extension of credit for personal, family or household purposes.
  2. Should credit availability be granted by Creditor, all credit shall be extended at the sole discretion of Creditor.
    Creditor may increase, decrease or terminate any credit availability at any time in its sole discretion.
  3. The terms and conditions of this credit application shall, upon extension of credit by Creditor, constitute an agreement of sale.
  4. Statements are rendered as of C.O.D. restrictions may be placed on any past due account.
    All invoices are due [insert terms]. A service charge of one and one half percent (12% per month), or (18% per annum) or the highest legal rate, whichever is less, may be assessed on delinquent invoices.
  5. This credit application is governed by the laws of the state of Texas.
  6. The parties hereto knowingly and intentionally waive the right to a jury trial on any issue or dispute that may arise between them.
  7. In the event of default, and if this account is turned over to an agency and/or an attorney for collection, the undersigned agrees to pay all reasonable attorney fees, and/or costs of collection whether or not satisfied.
  8. Applicant agrees to provide Creditor with an updated credit application annually as a condition for the continued extension of credit.

Section G - Personal Guarantee

This guarantee is given by the undersigned to Creditor, in order to induce and extend credit to, sell goods to, or otherwise become the creditor of, the Applicant.

I hereby guarantee to Creditor, the prompt payment, in accordance with the terms of credit, of every claim of Creditor, including claims relating to goods sold, open accounts and accounts stated, against the Applicant. This is a continuing guarantee and shall remain in force until revoked by the written consent of Creditor. This obligation shall cover the renewal of any claims guaranteed by those affected by any surrender or release by the seller of any security held by it for any claim hereby guaranteed.

The undersigned additionally guarantees the payment of interest at the maximum lawful rate on all monies outstanding to Creditor, by the Applicant, together with costs and reasonable attorney fees whether suit is brought or not and any attorney fees on appeal, which Creditor may incur in the collection of any claims. Further, the undersigned hereby submits himself/herself to the jurisdiction of the courts of Harris County, Houston, Texas in the event suit is brought in connection with any claim by Creditor regarding the guarantee of payment, and agrees that venue shall be in the county where Creditor has its principal place of business. It is understood and agreed by the undersigned that this personal guarantee shall remain in full force and effect regardless of whether the Applicant becomes insolvent or is otherwise dissolved.

In witness whereof, I have signed, and delivered this guarantee for the purposes set forth above on the day of , .
Sign Name:
Print Name:
Sign Name:
Print Name:

Section H - Consent to File UCC-1

The undersigned hereby consents the Creditor to file UCC-1 in consideration for the extension of credit and to secure the payment and performance of all obligations, and its affiliates, subsidiaries & divisions hereby grant Amijag™ Inc. a continuing purchase money security interest in all inventory, including but not limited to jewelry, gems, precious metal castings, watches, equipment, and goods, and all proceeds from the sale thereof; including payment intangibles, accounts, accounts receivables owed to Amijag™ Inc. by and its affiliates, subsidiaries & divisions.
Sign Name:
Print Name:
Sign Name:
Print Name:

(If you’re a corporation or LLC, or LLP, then an officer like a CFO would sign the business paperwork. If you’re a partnership, then both partners would sign; and if you’re a sole proprietor a copy of your unexpired drivers license is required in addition to the signatures)

Section I - Certification

Applicant certifies under penalty of perjury that the statements contained herein are true and correct. Applicant understands that Creditor intends to rely on all of the information presented in this application in determining the applicant’s credit-worthiness.