Credit Application Form
Thank you for applying for credit with Amazon Hose & Rubber Company. Our Accounting Department will reach out to you shortly with further account status.
Legal Business Name:
Do you have a DBA (Doing Business As) Name?
DBA (Doing Business As) Name:
Federal ID Number:
Type of Business:
Is your Physical Address the same as your 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":
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:
Additional Shipping Instructions:
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 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:
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:
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:
Join Our Newsletter?
Subscribe to Our Blog?
Ref #1 mailed _____ Received _____
Ref #2 mailed _____ Received _____
Ref #3 mailed _____ Received _____
Approved by: _________________
Credit Limit: _________________
Account #: _________________
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Credit Application Form
Agree & Sign