Hocks Noise Brakers®

Protect your hearing today, and hear the sounds of tomorrow

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Become an Authorized Noise Braker® Dealer!

Fill out the form below to become an authorized Hocks Noise Braker® dealer. You will be listed on our noisebrakers.com site as a state dealer of our custom made Hocks Noisebrakers®. (*) indicates that the field is required.

Company Name*:
Contact Name*:
Address*:
State*:
City*:
Zip Code*:
Phone Number (local)*:
Phone Number (toll-free):
Web Site Address:
E-mail Address:
Dispensing License#*:
Would you like to be listed as providing*:Custom Noise Brakers® Only
Custom & Standard Noise Brakers®
Standard Noise Brakers® Only
Do you wish to be signed up as an industrial provider?* **:YesNo
Do you take impressions on site?*:YesNo
* this field is required
** industrial providers are willing to take quantities of impressions for small to large orginizations.

1-800-OK-HOCKS
• P.O. Box 6616 Portland, OR 97228 • 800-654-6257 USA • 503-274-9482 local • 503-222-3539 fax •
email: contactus@noisebrakers.com
www.hocksproducts.com
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all rights reserved
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