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Online Credit Application
Please fill out this form completely to ensure timely processing of your application.

Select your location
Phoenix Las Vegas Anaheim Bakersfield Boise

Company information
Company name:
Phone: -- Fax (optional): --
Partnership Sole Owner Non-Profit Corporation

If business is a corporation (required only if applicable):
State of Articles of incorporation No. Date
Federal ID #: State Tax #:

Address information
Please indicate actual address, not P.O. box numbers
Billing address:
City: State: ZIP: How long?

Delivery address:
City: State: ZIP: How long?

Business information
Type of business:
P.O.s required? Yes No

Bank information
Account #: Bank name:
Account type: Phone: --

Trade references
Please provide three trade references.
Name:
Address:
City: State: ZIP:
Phone: -- Fax: --

Name:
Address:
City: State: ZIP:
Phone: -- Fax: --

Name:
Address:
City: State: ZIP:
Phone: -- Fax: --

I authorize Alternative Hose Inc. to investigate any bank or trade references listed above. In consideration of extensive credit by Alternative Hose Inc. to the applicant at any time from time to time hereafter, applicant agrees to pay for each purchase according to terms of purchase in effect at the time of each purchase as shown on its invoices, statements and quotations. Applicant further agrees to pay actual costs of collection including actual attorney's fees whether or not litigation is commenced or prosecuted to final judgment of any obligation arising hereafter to Alternative Hose Inc. in addition to the amount of the obligation.

Name:
Title:
E-mail address:
Date:

Clicking the button below serves as your signature.





Phoenix
602.269.6900


Mesa
480.699.0990


Las Vegas
702.633.4449


Anaheim
714.414.0904


Azusa
626.334.7130


Loma Linda
909.796.1111


Wilmington, CA
310.835.5651


Boise
Andy's Supply
208.344.3568


Atlanta
678.741.6900