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 - DOWNLOAD ACH PAYMENT INFORMATION

APPLICANT INFORMATION

Company Name *

Single Line Text *

Tax ID# *

Company Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Phone (copy)

Website / URL *

Please mark which one of the following applies... *

Corporation
Partnership
Individual
Incorporated within past 12 months

INVOICE TO INFORMATION

Bill to Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Accounts Payable Contact *

First

Last

A/P Email *

A/P Phone *

Preferred method of payment - please check one *

ACH
Check
Credit Card (4% processing fee)

SHIPPING INFORMATION

Enter as many addresses as apply to you

Shipping Address #1 *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Shipping Address #2

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Shipping Address #3

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Standard Shipping Method - generally less than 150 LBS

Standard Collect#

Standard LTL Method - more than 150 LBS or pallet packaging

Standard LTL#

BUSINESS REFERENCES

Reference #1 *

Contact 1 *

Email 1 *

Phone 1 *

Fax 1

Reference #2 *

Contact 2 *

Email 2 *

Phone 2 *

Fax 2

Reference #3 *

Contact 3 *

Email 3 *

Phone 3 *

Fax 3

Reference #4 *

Contact 4 *

Email 4 *

Phone 4 *

Fax 4

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 *

First

Last

Date of signature *

SALES TAX EXEMPTION FORM

Please fill out the sales tax exemption form if applicable, otherwise the appropriate sales tax will be charged to all invoices. 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 *

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

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Signature *

First

Last

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

Date / Time *

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 your own pre-filled Tax Exemption form here

Click or drag a file to this area to upload.

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