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Application
Diamond Dealers Club Member
Applicant's Information
*
Indicates required field
Name
*
First
Last
Mid Initial/s
*
Home Address
*
Apt #
*
City
*
State
*
Zip Code
*
Country
*
Home Telephone
*
Cell Phone
*
Include Country Code if Outside US
Personal Email Address
*
Date of Birth
*
(MM/DD/YYYY)
Country of Citizenship
*
Picture
*
Max file size: 20MB
Please upload a picture of yourself.
Company Information
Company Name
*
Company Type
*
Corporation
Partnership
Sole Proprietor
Street Address
*
Suite #
*
City
*
State
*
Zip Code
*
Country
*
(Include Country Code if Outside US)
*
Company Telephone
*
Fax Number
*
Work Email Address
*
Website
*
Title/Position
*
Ownership Percentage
*
%
Other Shareholders
Name
*
Title
*
Ownership
*
%
Name
*
Title
*
Ownership
*
%
State of Incorporation/Business Certificate
State
*
County
*
Federal Tax ID Number
*
Experience in the Diamond, Jewelry, or Gemstone Business
Years
*
Company/Location
*
What is the Nature of Your Business?
*
Trade References
(Please provide four references)
Ref. 1: Company
*
Contact
*
Years of Contact with Company
*
Address
*
City
*
State
*
Telephone
*
(Include Country Code if Outside USA)
Ref. 2: Company
*
Contact
*
Years of Contact with Company
*
Address
*
City
*
State
*
Telephone
*
(Include Country Code if Outside USA)
Ref. 3: Company
*
Contact
*
Years of Contact with Company
*
Address
*
City
*
State
*
Telephone
*
(Include Country Code if Outside USA)
Ref. 4: Company
*
Contact
*
Years of Contact with Company
*
Address
*
City
*
State
*
Telephone
*
(Include Country Code if Outside USA)
Are you listed in JBT?
*
Yes
No
If Yes:
*
JBT Number
Are you or have you ever been member of a diamond club that is affiliated with the World Federation of Diamond Bourses?
*
Yes
No
If Yes:
*
Name of WFDB Diamond Bourse
Year of Admission
*
Are you party to any pending arbitration or lawsuit?
*
Yes
No
Have you any unpaid judgments or arbitration awards against you or your company?
*
Yes
No
Have you ever filed a bankruptcy petition personally or on behalf of your company?
*
Yes
No
Have you ever been arrested for, charged with, or convicted of a felony or a misdemeanor?
*
Yes
No
(If yes, please include an explanation in the comment box below)
Please use the box below for any additional information or explanation.
*
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