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Company Name


*Street Address




*Phone Number

Fax Number

*E-Mail Address


Type of Business

AP - Auto Parts OS - O.E.S. TP - Truck Parts Dist
EX - Exporter RL - Reliner TR - Trailer Dealer
FD - Fastener Dist SS - Spring Shop TS - Truck Stop
HD - Hardware Dist TD - Truck Dealer UP - Used Parts/Salvage
OE - O.E.M. TJ - Tire Jobber OT - Other

Buying Group

HDA - HD America PHD - Power Heavy Duty
IWDI - Truck Pride VHD - VIPAR Heavy Duty

Brands Stocked (Mark those that apply)

Anchorlok Euclid MGM
Batco/Dayton Federal Mogul Midland
Bendix Fruehauf North Coast
Bepco Great Lakes New Life
Bower/BCA Gunite Neway
BWP Haldex OBI
CHGO Rawhide Hayes Parts America
Dana Hendrickson SCI
Dexter Hyatt Trailmobile
Eagle/Norcross Leland/Ferodo Tramec
Eaton Meritor TSE

Request (Mark those that apply)

Sales Literature/Catalog Price Comparison to
Interchange to WD Price Sheet