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Dealer Signup


On behalf of all the staff at PLACE FOR BRAKES, I would like to thank you for your interest in our fine products.

In order to better service our customers we would like to first ascertain the nature of your business and your desired intention for our products. In order to assist us in this exercise we kindly ask you to complete this form and return it to us.


Company Information:
Please enter your company information below:
Company Name: *
Contact Name: *
Street Address: *
City: *
State/Province: *
Postal Code (ZIP): *
Country: *
Telephone: *
Telephone 2:
Company E-mail: *
Company Website:
Mailing Address
If different from above.
Street Address:
Postal Code (ZIP):
Business Description
(Must be completed, 25 words or less)
What is the nature of your business?
Are you currently stocking inventory?

Sole/Exclusive Distributor
Street Rod Dealer/Retailer
Car Dealer
Tire Dealer
Mail-Order Company
E-commerce Business
WD (Warehouse Distributor)
General Automotive Repair
Do you sell retail?
Do you offer installation?
Comments or Special Instructions
Security Code
Please type the security code that appears on the left.
Reload Image
Please email your reseller tax ID to: .
Submit Your Request Reset This Form
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