Credit Application Form

Welcome and thank you for applying for a charge account with Amazon Hose & Rubber Company. Payment is due Net 30 days from invoice date. 1-1/2% interest on accounts over 30 days past due. No price corrections or returns (except for defective merchandise) after 30 days from invoice date. Special order merchandise is non-refundable/non-returnable. Receipt is required for returns and may be subject to a 25% restocking fee. All accounts will be charged sales tax unless a current tax exemption certificate is provided to keep on file. Accounts with unpaid invoices 45 days from invoice date will be placed on credit hold. Charge backs for expenses incurred in collections to include, but not limited to, attorney's fees. $25.00 NSF check fee.

Shipping Instructions

Preferred Carrier:*

Carrier Payment:

Prepaid & Add
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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:*

Trade References

Select the option below to provide your Trade References.*

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Please provide at least 3 Trade References.

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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 terms for extension of credit are 30 days NET. Amazon Hose reserves the unconditional right to refuse credit or to close any account, at any time, without prior notice. Closed credit accounts become payable, in full, immediately. Signature indicates acceptance of all terms listed above.

Date:*

Name Filing for Credit:*

First Last

Title/Position:*

Email Address:*

Credit Limit Requested:*

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

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No

If yes, who are you working with?*

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

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Telephone:*

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Company Information

Shipping Instructions

Company Officers

Trade References

Terms and Conditions