USE THE FORM ON THIS PAGE TO SET UP NET30 TERMS 

 

Need to fill out this application offline? No problem! Just download the Credit Application and email the completed form back to us at sales@cutandcouple.com or fax to (937) 454-2086

 

DOWNLOAD CREDIT APPLICATION

CREDIT APPLICATION

"*" indicates required fields

APPLICANT INFORMATION

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

INVOICE TO INFORMATION

Bill To Address*
Accounts Payable (A/P) Contact*
Preferred method of payment - please check one*

SHIPPING INFORMATION

Enter as many addresses as apply to you
Shipping Address #1*
Shipping Address #2
Shipping Address #3

BUSINESS REFERENCES

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 CUT & COUPLE's credit terms and agree to proper payment in consideration of extended credit. TERMS: 1% 10 Net 30 unless agreed upon by both parties.
Name of person filling out this form*
MM slash DD slash YYYY

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.
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:
Purchaser must state a valid reason for claiming exception or exemption
Purchaser's Name
Address
Signature
By entering your NAME above and DATE SIGNED below, you are certifying that all information on this Tax Exemption form is correct.
MM slash DD slash YYYY
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.
Max. file size: 5 MB.
FILE TYPES ALLOWED: .pdf, .doc, .docx, .jpg

Shopping cart2
Patriot 1787 Hose
STEP 1 - Choose Hose and Enter Length in FEET:

Patriot® 1787 Petroleum Hose

STEP 2 - Choose Fitting #1:

SS 316 Female Locking Camlock x Hose Barb - PART C - Ferrule Included

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STEP 3 - Choose Fitting #2:

NO FITTING

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OPTIONAL - Pressure Testing and Tagging:

No Additional Options

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SS 316 Female Camlock x Hose Barb
Subtotal
$363.38
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