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Dear Vendor and Business Partner:

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 vendors. Please provide the following identifying information.


Martin Kirschenbaum, Inc.,
580 Fifth Avenue, Suite 606,
New York, NY 10036,
Tel: 212-575-0030; Toll Free: 1-888-777-0030

www.mkiny.com

Vendor Patriot Act Profile

Fields marked with an asterisk * are required
Contact Name*:
Company Name*:
Address 1*:
Address 2:
City*:
State*(US ony):
Zip*(US only):
Province (CA):
Postal Code (CA):
Other:
Country*:
Telephone Number*:
Fax Number*:
Contact Email*:
Alt Email
Federal Tax ID Number*:
Resale certificate number:
YES   We have or will be instituting an AML Program
NO   We will not institute an AML program due to our status being "exempt"
Your AML Compliance* Officer*:
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