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.


Company Information

Legal Business Name:

Do you have a DBA (Doing Business As) Name?

DBA (Doing Business As) Name:

Federal ID Number:


NAICS/Industry Code:

Business Classification:

Type of Business:

Company Website:

Physical Address:

Is your Physical Address the same as your Billing/Mailing Address?

Billing/Mailing Address:

Do you have any additional ship to locations?


If "Yes, 1-2 locations":

Additional Address 1:

Additional Address Telephone 1:

Additional Address 2:

Additional Address Telephone 2:


If "Yes, 3+ locations":

Uploaded files:


Business Telephone:

Business Fax:

Please provide the Email Address where Invoices are to be sent.

Please provide the Email Address where Statements are to be sent.

Are Purchase Orders Required?

Years in Business:

Are you Tax Exempt?

Upload Tax Certificate:

Upload Bank References:


Shipping Instructions

Preferred Carrier:

Carrier Payment:

Additional Shipping Instructions:


Company Officers

Principal or Owner Name:


Principal or Owner Address:

Principal or Owner Email:

Principal or Owner Telephone:

Additional Principal or Owner Name:


Additional Principal or Owner Address:

Additional Principal or Owner Email:

Additional Principal or Owner Telephone:

Sales Manager Name:


Sales Manager Address:

Sales Manager Email:

Sales Manager Telephone:

Purchasing Manager Name:


Purchasing Manager Address:

Purchasing Manager Email:

Purchasing Manager Telephone:

Accounts Payable Name:


Accounts Payable Address:

Accounts Payable Email:

Accounts Payable Telephone:


Trade References

Uploaded References:


Typed References:

Trade Reference Company Name 1:

Trade Reference Contact Name 1:

Trade Reference Account Number 1:

Trade Reference Address 1:

Trade Reference Email 1:

Trade Reference Telephone 1:

Trade Reference Fax 1:

Trade Reference Company Name 2:

Trade Reference Contact Name 2:

Trade Reference Account Number 2:

Trade Reference Address 2:

Trade Reference Email 2:

Trade Reference Telephone 2:

Trade Reference Fax 2:

Trade Reference Company Name 3:

Trade Reference Contact Name 3:

Trade Reference Account Number 3:

Trade Reference Address 3:

Trade Reference Email 3:

Trade Reference Telephone 3:

Trade Reference Fax 3:

Trade Reference Company Name 4:

Trade Reference Contact Name 4:

Trade Reference Account Number 4:

Trade Reference Address 4:

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.



Name Filing for Credit:


Email Address:

Credit Limit Requested:

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

If yes, who are you working with?

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

If 'Yes', Telephone:

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Subscribe to Our Blog? 



For Office Use Only:

References Mailed:

Ref #1 mailed _____ Received _____

Ref #2 mailed _____ Received _____

Ref #3 mailed _____ Received _____


Account Approval:





Approved by: _________________

Credit Limit: _________________

Account #: _________________

Leave this empty:

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Signature Certificate
Document name: Credit Application Form
lock iconUnique Document ID: 77f586d43d419322fa8b49bab2cc561b2c3b8cec
Timestamp Audit
03/02/2017 4:36 pm GMTCredit Application Form Uploaded by Ashley Miranda - IP