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.


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 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:


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: 8a93184b6c8389f85140ed1d7b9872e34c1586a6
Timestamp Audit
03/02/2017 4:36 pm GMTCredit Application Form Uploaded by Ashley Miranda - IP
04/20/2023 10:27 am GMTAccounting - added by Ashley Miranda - as a CC'd Recipient Ip:
04/20/2023 10:27 am GMTTheresa Duboise - added by Ashley Miranda - as a CC'd Recipient Ip:
04/21/2023 3:01 pm GMTAccounting - added by Ashley Miranda - as a CC'd Recipient Ip:
04/21/2023 3:01 pm GMTTheresa Duboise - added by Ashley Miranda - as a CC'd Recipient Ip: