United States Postal Service
Application for Delivery of Mail Through Agent
See Privacy Act Statement on Reverse                                                1. Date 

In consideration of delivery of my or our (firm) mail to the agent named below, the addressee and agent agree: (1) the addressee or the agent must not file a change of address order with the Postal Service upon termination of the agency relationship; (2) the transfer of mail to another address is the responsibility of the addressee and 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 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 7 or 10, and that the identification listed in box 8 is valid.

4. Applicant Authorizes Delivery to and in Care of
(Name, address, and ZIP Code of agent)
         

5.This Authorization Is Extended to Include Restricted Delivery Mail for the Undersigned(s)

6. Name of Applicant
     

7. Applicant Home Address (Number, street, city, state, and ZIP Code)
        
Telephone Number    

8.Two types of identification are required. One must contain a photograph of the addressee(s). Social Security cards, credit cards, and birth certificates are unacceptable as identification. The agent must write in identifying information. Subject to verification.
     ____________________________________________
     a.
     ____________________________________________
     b.
     ____________________________________________
Acceptable identification includes: valid driver's license or state non-driver's identification card; armed forces, government, university or recognized corporate identification card; passport or alien registration card or certificate of naturalization; current lease, mortgage or Deed of Trust; voter or vehicle registration card; or a home or vehicle insurance policy. A photocopy of your identification may be retained by agent for verification.

9. Name of Firm or Corporation
      

11. Kind of Business
      

12. 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.)
         

13. If a CORPORATION, Give Names and Addresses of Its Officers
        

14. 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 or misleading 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)

15. Signature of Agent/Notary Public

16. Signature of Applicant (If firm or corporation, application must be signed by officer. Show title.)

PS Form 1583, August 2000 (Page 1 of 2)                                                           This form on Internet at www.usps.com

"Privacy Act Statement: The collection of this information is authorized by 39 USC 403 and 404. This information will be used to authorize the delivery of the intended addressee's mail to another. The Postal Service may disclose this information to an appropriate government agency, domestic or foreign, for law enforcement purposes; where pertinent, in a legal proceeding to which the USPS is a party or has an interest; to a government agency in order to obtain or provide information relevant to an agency decision concerning employment, security clearances, contracts, licenses, grants, permits or other benefits; to a congressional office at your request; to an expert, consultant, or other person under contract with the USPS to fulfill an agency function; to the Federal Records Center for storage; and for the purpose of identifying an address as an address of an agent to whom mail is delivered on the behalf of other persons.  Information concerning an individual who has filed an appropriate protected court order with the postmaster will not be disclosed in any of the above circumstances except pursuant to the order of a court of competent jurisdiction. Completion of this form is voluntary; however, without the information, the mail will be withheld from delivery to the agent and delivered to the addressee, or, if the address of the addressee is that of the agent, returned to the sender."