Thank you for your interest in Brickel's Racing Collectibles, Inc. We appreciate the opportunity to provide you with confidential wholesale pricing information. Upon request and approval of your "new dealer" application, we will forward our pricing information to you.
Please fill out this form entirely. Make sure to attach a copy of your business license, state sales tax exempt form, a canceled/voided business check, interior pictures of your retail store and exterior pictures with the attached business sign to this form.
Failure to provide all requested information may cause a delay in processing your new dealer application.

Business Name
Business Phone Business Fax Alternate
Shipping Address
City State Zip
Billing Address
City State Zip
How Long Have You Been in Business?        __________Years         __________Months         New Business
Type of New Ownership? (check one)    Individual    Partnership    Corporation    SCorp    LLC
Email Address:
Would like to be added to our e-mail list?       Add Me to the List       Do Not Add Me to the List
Emails are strictly business related to new merchandise or information pertaining to the business.
Web Site Address
Owner's Full Name
Owner's Social Security Number
Owner's Home Address
City State Zip
Owner Officer 1: Name Title
Owner Officer 2: Name Title
Owner Officer 3: Name Title
Store Manager Name(s): 1. 2.
Assistant Manager Name(s): 1. 2.
Type of Business & Products Sold?
References
Name Address
City State Zip
Phone Number Contact Person
Name Address
City State Zip
Phone Number Contact Person
Name Address
City State Zip
Phone Number Contact Person