Credit Application Form

Date

Company Officers

Principal or Owner Name:*

First Last

Title/Position:*

Principal or Owner Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Principal or Owner Email:

Principal or Owner Telephone:*

Additional Principal or Owner Name:

First Last

Title/Position:

Additional Principal or Owner Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Additional Principal or Owner Email:

Additional Principal or Owner Telephone:

Sales Manager Name:*

First Last

Title/Position:*

Sales Manager Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Sales Manager Email:*

Sales Manager Telephone:*

Purchasing Manager Name:*

First Last

Title/Position:*

Purchasing Manager Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Purchasing Manager Email:*

Purchasing Manager Telephone:*

Accounts Payable Name:*

First Last

Title/Position:*

Accounts Payable Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Accounts Payable Email:*

Accounts Payable Telephone:*

Purchase Order Information

Are Purchase Orders Required?*

Yes
No

Email Address where Invoices are to be sent:*

Email Address where Monthly Statements should be sent:

Shipping Instructions

Carrier Payment:

Prepaid & Add
Collect

Preferred Carrier:*

Preferred Carrier Account #:

Additional Shipping Instructions:

Principal Bank Reference

Name of Bank*

Bank Account #:*

Bank Officer

Bank Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Bank Telephone:*

Upload Bank References:

Drop files here or

Max. file size: 50 MB, Max. files: 2.

If you wish to upload your Bank References, please do so here.

Trade References

Select the option below to provide your Trade References.*

Upload File with Trade Reference information
Type Trade Reference information on this form

Please provide at least 3 Trade References.

Upload Trade References:

Drop files here or

Max. file size: 50 MB, Max. files: 4.

If you wish to upload your Trade References, please do so here.

Trade Reference Company Name 1:*

Trade Reference Address 1:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Trade Reference Account Number 1:*

Trade Reference Contact Name 1:*

First Last

Trade Reference Email 1:*

Trade Reference Telephone 1:*

Trade Reference Fax 1:*

Trade Reference Company Name 2:*

Trade Reference Address 2:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Trade Reference Account Number 2:*

Trade Reference Contact Name 2:*

First Last

Trade Reference Email 2:*

Trade Reference Telephone 2:*

Trade Reference Fax 2:*

Trade Reference Company Name 3:*

Trade Reference Address 3:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Trade Reference Account Number 3:*

Trade Reference Contact Name 3:*

First Last

Trade Reference Email 3:*

Trade Reference Telephone 3:*

Trade Reference Fax 3:*

Trade Reference Company Name 4:

Trade Reference Address 4:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Trade Reference Account Number 4:

Trade Reference Contact Name 4:

First Last

Trade Reference Email 4:

Trade Reference Telephone 4:

Trade Reference Fax 4:

Terms and Conditions

Business/Applicant hereby acknowledges the following: The information supplied is complete and accurate. Amazon Hose reserves the unconditional right to refuse credit or to close any account, at any time without prior notice. Closed credit account become payable, in full immediately. Signature below indicates acceptance of all terms listed below and provided in the TERMS AND CONDITION OF SALE page as follows.

Name Filing for Credit:*

First Last

Title/Position:*

Email Address:*

Telephone:*

Are you currently working with one of our Territory Managers/Outside Sales?*

Yes
No

If yes, who are you working with?

Would you like one of our Sales Representatives to contact you?

Yes, please reach out!
No, thanks.

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Phone

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Company Information

Company Officers

Purchase Order Information

Shipping Instructions

Principal Bank Reference

Trade References

Terms and Conditions