Form 1583


Application for Delivery of Mail Through Agent See Privacy Act Statement on Reverse	1. Date:
In consideration of delivery of my or our mail to the agent named below, the addressee and agent agree that: (1) the addressee or agent must not file a change of address order with the Postal Service upon termination of the agency relationship; initial _____ (2) the transfer of my or our (firm) mail to another address is the responsibility of the agent; (3) all mail delivered to the agency under this authorization must be prepaid with new postage when redeposited in the mails; (4) upon request the agent must provide to the Postal Service all addresses to which the agency transfers mail; and (5) when any information required on this form changes or becomes obsolete, the addressee(s) must file a revised application with the Commercial Mail Receiving Agency (CMRA). NOTE: The applicant must execute this form in duplicate in the presence of the agent, his or her authorized employee, or a notary public. The agent agent provides the original completed signed Form 1583 to the Postal Service and retains a duplicate completed signed copy at the CMRA business location. The CMRA copy of Form 1583 must at all times be available for examination by the postmaster (or designee) and the Postal Inspection Service. The addressee and the agent agree to comply with all applicable postal rules and regulations relative to delivery of mail through an agent. Failure to comply will subject the agency to withholding of mail from delivery until corrective action is taken. This application may be subject to verification procedures by the Postal Service to confirm that the applicant resides or conducts business at the home or business address listed in boxes 8 or 11, and that the identification listed in box 9 is valid.
2. Name(s) in which applicant's mail will be received for Delivery to Agent. (Complete a separate Form 1583 for EACH applicant. Spouses may complete and sign one Form 1583. Two valid identification apply to each spouse. Include dissimilar information for either spouse in appropriate box.)	3. Address to Be Used for Delivery including ZIP + 4 (no other address designation is allowed) Your Name or Business Here 2509 N. Campbell # ______ Tucson, AZ 85719 *(The words Suite # or APT # are NOT allowed per DMM regulations)*
4. Applicant Authorizes Delivery to and in Care of (Name, address and ZIP code of agent) Letterbox 2509 N. Campbell Tucson, AZ 85719	5. Will This Delivery Address Be Used for Soliciting or Doing Business With the Public? (Check one) ___ Yes ___ No
6. This Authorization is Extended to Include Restricted Delivery Mail for the Undersigned(s).	7. Name of Applicant
8. Home address (Number, street, city, state and Zip code) Telephone number (Include Area Code)	9. Two Types of Identification are Required. One Must Contain a Photograph of the Addressee(s). Agent Must Write in Identifying Information. Subject to Verification. 1.__________________________________________________ 2.__________________________________________________ Acceptable identification include: drivers license; armed forces, government, or recognized corporate identification card; passport or alien registration card or other credential showing the applicant's signature and a serial number or similar identification that is traceable to the bearer. A photocopy of your identification may be retained by agent for verification.
10. Name of Firm or Corporation
11. Business address (Name, street, city, state and Zip code) Telephone number (Include Area Code)	12. Kind of Business
13. If Applicant is a Firm, Name Each Member Whose Mail is to Be Delivered. (All names listed must have verifiable identification. A guardian must list the names and ages of minors receiving mail at their delivery address.)	14. If a CORPORATION, give names and addresses of its officers
15. If Business Name of The Address (Corporation or Trade Name) Has Been Registered, Give Name of County and State, and Date of Registration.	Warning: The furnishing of false information on this form or omission of material information may result in criminal sanctions (including fines and imprisonment) and/or civil sanctions (including multiple damages and civil penalties). (18 U.S.C. 1001)
16. Signature of agent/Notary Public	17. Signature of applicant (If firm or corporation, applicant must be signed by office. Show title.)
WWW PS Form 1583-REVISED, October 1999