Customer ID Verification Form

TMT, P.o.Box 3155, Renton WA 98056 - Tel 425-227 7762, Fax 425-2550345

Customer information

Name:

Address:

City: State: Zip code ___________

Telephone: Cell-phone: E-mail:

Identification Information

Social Security Number:

Date of Birth: Occupation:

ID #____________ _____________ ID TYPE: _________________________________

Issued at : (state) Valid until date:

City: Country :

I hereby certify that the above information is correctly filled out.

Applicant Signature: Date:

*** This portion is to be filled out by a public notary ****

CERTIFICATE OF ACKNOWLEDGMENT

State of: _____________________________, County of ________________________,

On _________, 20 _____ before me, __________________________ Notary Public in and for said

county, personally appeared _______________________________________________,who has satisfactorily identified him/herself as the signer to the above-referenced document.

Notary Stamp here:

My Commission Expires _____________, _________________, _______________

(Expiration date) (Notary Signature) (Date)

TMT is a licensed Money Service Business registered in Washington State.

Tel: 1-425-227 7762 Fax:1-425-255 0345 E-mail: transhorn@ertra.com