Credit Application:

    Business Information

    Company Name*

    Nature of Business*

    Phone*

    Fax

    Company Physical Address*

    City*

    State*

    Zip code*

    How long at current address?*

    Date business commenced*

    Type of Business*CorporationLLCOther

    State of Incorporation*

    TIN, EIN, or SSN*

    PO# required?* YesNo

    Amount of credit requested*

    Amount of estimated purchases*

    Purchaser Name*

    Purchaser Email*

    Name of person responsible for payments*

    Title of person responsible for payments*

    A/P Email*

    Invoices and statements required?*YesNo

    Via?FaxEmail

    Business and Credit Information

    Bank Name*

    Bank Address*

    Bank Phone*

    Bank City*

    Bank State*

    Bank Zip Code*

    Type of Account*CheckingSavings

    Account Number*

    Business and Trade References

    *Please include valid fax numbers and/or email addresses for all references*

    Company Name*

    Address*

    City*

    State*

    Zip Code*

    Terms on account*

    Phone*

    Fax

    Email*

    Company Name*

    Address*

    City*

    State*

    Zip Code*

    Terms on account*

    Phone*

    Fax

    Email*

    Company Name*

    Address*

    City*

    State*

    Zip Code*

    Terms on account*

    Phone*

    Fax

    Email*

    Agreement

    1) All invoices are to be paid 30 days from the date of the invoice.

    2) Claims arising from invoices must be made within seven working days.

    3) By submitting this application, you authorize All Hose to make inquires into the banking and business / trade references that you have supplied.

    4) Any costs or fees All Hose incurs to collect and receive payment (i.e. collections fees, lawyer's fees) will be paid by the company applying for credit on this application.

    5) Any past due invoices are subject to a 1.5% monthly interest fee.

    6) Payments made on account by credit card are subject to a 4% processing fee.

    7) New accounts may be subject to a 50% deposit of large orders placed.

    Signature*

    Print Name*

    Title*

    Date*

    *Not used for SMS

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