Credit Application

CREDIT APPLICATION

Please fill out and submit the form below to be considered for NET 30 Terms.

DISCLAIMER: U.S. Hose & Coupling only sells to distributors and qualified OEM's. If you would like to be referred to a distributor, click HERE.

If you have questions, contact our Accounts Receivable team at
(800) 344-0150 - ar@ushoseco.com

DOWNLOAD CREDIT APPLICATION - UPLOAD CREDIT APPLICATION
DOWNLOAD ACH PAYMENT INFORMATION

APPLICANT INFORMATION

Company Name(Required)

Years in business(Required)

Tax ID(Required)

Company Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number(Required)

Fax Number

Website

Please mark which one of the following applies...(Required)

Corporation

Partnership

Individual

Incorporated within the last 12 months

INVOICING INFORMATION

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Accounts Payable (A/P) Contact(Required)

First Last

A/P Email(Required)

A/P Phone Number(Required)

Preferred method of payment - please check one(Required)

ACH

Check

Credit Card (4% Processing Fee)

SHIPPING INFORMATION

Enter as many addresses as apply to you

Shipping Address (MAIN)(Required)

Street Address Address Line 2 City State ZIP Code

Shipping Address #2

Street Address Address Line 2 City State ZIP Code

Shipping Address #3

Street Address Address Line 2 City State ZIP Code

Standard Shipping Carrier - generally less than 150 lbs

Standard Carrier Account Number

Standard LTL Shipping Method - over 150 lbs or pallet packaging

Standard LTL Account Number

BUSINESS REFERENCE #1

Company(Required)

Contact Name(Required)

First Last

Contact Email(Required)

Contact Phone Number(Required)

Contact Fax Number

BUSINESS REFERENCE #2

Company(Required)

Contact Name(Required)

First Last

Contact Email(Required)

Contact Phone Number(Required)

Contact Fax Number

BUSINESS REFERENCE #3

Company(Required)

Contact Name(Required)

First Last

Contact Email(Required)

Contact Phone Number(Required)

Contact Fax Number

BUSINESS REFERENCE #4

Company(Required)

Contact Name(Required)

First Last

Contact Email(Required)

Contact Phone Number(Required)

Contact Fax Number

SIGNATURE

PLEASE REVIEW THE INFORMATION YOU HAVE DETAILED ABOVE BEFORE SIGNING.

By entering your NAME and DATE SIGNED below, you are certifying that all information on this form is correct and that you fully understand U.S. Hose & Coupling's credit terms and agree to proper payment in consideration of extended credit.

TERMS: Net 30 unless agreed upon by both parties.

Name of person filling out this form(Required)

First Last

Date of signature(Required)

SALES TAX EXEMPTION FORM

Please fill out the sales tax exemption form otherwise the appropriate sales tax will be charged to all invoices.
NOTE: If you have your own Tax Exemption form, you may upload it using the file uploader located at the end of this form instead.

Sales and Use Tax Blanket Exemption Certificate - Name "VENDOR" Below

The purchaser listed above ("Vendor") hereby claims exception or exemption on all purchases of tangible personal property and selected services made under this certificate.
The Vendor also certifies that the claim is based upon the purchaser's proposed use of the items or services, the activity of the purchase, or both, as listed below:

Claim

Purchaser must state a valid reason for claiming exception or exemption

Purchaser's Name

First Last

Purchaser's Address

Street Address Address Line 2 City State ZIP Code

Signature

By entering your NAME above and DATE SIGNED below, you are certifying that all information on this Tax Exemption form is correct.

Date

Title of Signee

Vendor's License Number (if any)

Vendors of motor vehicles, titled watercraft and titled outboard motors may use this certificate to purchase these items under the "resale" exception. Otherwise, purchaser must comply with either rule 5703-9-10 or 5703-9-25 of the Administrative Code. This certificate cannot be used by construction contractors to purchase material for incorporation into real property under an exempt construction contract. Construction contractors must comply with rule 5703-9-14 of the Administrative Code.

FILE UPLOADER - Attach you own pre-filled Tax Exemption form here

Max. file size: 5 MB.

FILE TYPES ALLOWED: .pdf, .doc, .docx, .jpg