• 1Company Information
  • 2Billing
  • 3Shipping
  • 4References
  • 5Complete

Midwest Hose Credit Application Form

Please fill out all items in this form to begin the credit application process.

Business Information
Billing Address
Physical Address
Organization Type
Detailed Business Information
Billing Information
Will your company pay from an electronically generated invoice?
What is your preference for receiving invoices?
What is your preference for receiving statements?
What are your invoice requirements? (check one)
Are Purchases Tax Exempt?
Purchaser Name
Shipping Address
Bank Information
Bank Address
Bank Officer
Account Information
Trade Reference 1
Trade Reference 2
Trade Reference 3
Trade Reference 4

Ready for submission

If the undersigned individual who is either a principal of the credit application or a sole proprietorship of the credit applicant, recognizing that his or her individual credit history may be a factor in the evaluation of the credit history of the above Application, hereby consents and authorizes the use of a consumer credit report on the undersigned by the above named business credit grantor, from time to time as may be needed, in the credit evaluation process.

Applicant agrees to make payment in full to Midwest Hose & Specialty, Inc. for all amounts due according to Midwest Hose & Specialty’s invoice(s). All transactions with Midwest Hose & Specialty, Inc. are subject to Midwest Hose & Specialty, Inc.’s terms and conditions. Should Applicant default in any such payment(s), Midwest Hose & Specialty, Inc. shall have the right, without notice to Applicant, to declare all invoices amounts due and payable. In the event that Midwest Hose & Specialty, Inc. should commence any action or actions, or otherwise seek to enforce this agreement against Applicant, Applicant agrees to pay reasonable finance charges, attorney(s) fees, court costs, and other expenses incurred by Midwest Hose & Specialty, Inc. whether or not suit is filed. This agreement is strictly confidential and is not transferable or assignable without the prior written consent of Midwest Hose & Specialty, Inc. No act or omission of Midwest Hose & Specialty inc. will be deemed to constitute a waiver of any of its rights absent an express, written statement to that affect.

Applicant agrees that any changes in liability for any debts incurred to Midwest Hose & Specialty, Inc. due to change in Applicant’s form of business or ownership shall not be effective as to Midwest Hose & Specialty, Inc., until Midwest Hose & Specialty, Inc., received actual notice of the change by certified mail.

Applicant certifies that Midwest Hose & Specialty, Inc. is hereby authorized to make inquiries concerning our payment history, billing records, and other activity pertaining to all of our accounts and services with you.

Credit Application Transmission Succesful