Purchase - Recycling of Precious Metals package with our attached letter AMP Recycling SA. Information : Company / Dental office / Dental laboratory : _______________________________________________________ (for private parties indicate name) Initial contact (via telephone, internet, etc.) : _______________________________________________________ Address (street & no.) : ________________________________________________________________________ City, country & postal code : ____________________________________________________________________ Tel : ________________________________________________________________________________________ E-mail : ____________________________________________________________________________________ Do you qualify for a VAT deduction ? : ( ) Yes (industry) ( ) No (private party) Tax ID No. or VAT No. : ________________________________________________________________________ Information about your recyclable materials : _______________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Description of items sent : _______________________________________________________________________________ Which metals do you think the items contain? (Au, Ag, Pd, Pt, Rh, Ta) : _________________________________________ Method of payment desired : ( ) Wire to my bank account (provide following info.) Bank : ___________________________________________________ IBAN : ________________________________________________________________________________________________ BIC : _________________________________________________________________________________________________ Account holder (if different) : _____________________________________________________________________________ ( ) Wire to my weight account ( ) Check sent by mail Sworn statement of ownership : I swear under oath to be a legal adult (minimum of 18 years of age) and that the materials for purchase by AMP Recycling SA. are my own property, free from debt, and are not the proceeds from a criminal act. Location : _________________________ Date : ____________ Signature : _____________________________ Please use an envelope or box suitable for mailing. We will contact you when we receive your material. We can provide you with packing materials if you haven't any. Return