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US PATRIOT ACT/AML Compliance Form - Company

Fill this form out, then print and include with your first order.

MIDWEST REFINERIES
4471 Forest Ave.
Waterford, Michigan 48328


General Information
Company Name
Contact Name
Address
City
State Zip
Telephone - - Fax - -
E-Mail Address
Website Address
Previous Address If Moved In Last Five Years
Company Information
Type Of Company

  Year Established State
Federal ID #
State Resale Tax ID # (Please provide copy)
Names Of Key Officers D.O.B / /
D.O.B / /
Type Of Business
Other
Does your company import or export goods to / from outside the United States?

Does your company have an Anti-Money Laundering Program in place?



Parent Company Information (Skip if N/A)
Name Of Parent Company
City State
Bank Information
Bank Name
Address
City
State Zip
Telephone - - Account #
Bank Contact
Trade Associations
Please choose any associations you are a member of.
(Ctrl + Click to select multiple)


Others

Required