Ps Form 1583 - Beverly Hills United Mailboxes - 2004

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United S tates Postal S ervice ®
Appl ication for Delivery of Mail Throu gh Agent
1 . Date
S ee Privacy Act S tatement on R everse
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 S ervice™ 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 a uthorization
must be prepaid with new postage when redeposited in the mails; (4) upon request the agent must provide to the Postal S ervice a ll
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 R eceiving Agency (CMR A).
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 PS Form 1 583 to the Postal S ervice and retains a duplicate completed signed copy at
the CMR A business location. The CMR A copy of PS Form PS 1 583 must at all times be available for examination by the postmaster (or
designee) and the Postal Inspection S ervice. The addressee and the agent agree to comply with all applicable Postal S ervice 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 S ervice to confirm that the applicant resides or conducts business
at the home or business address listed in boxes 7 or 1 0, and that the identification listed in box 8 is valid.
2. Name in Which Applicant's Mail Will Be R eceived for Delivery to Agent.
3a.Address to be Used for Delivery
(MUST include PMB or # Sign with Box number on all mail & Parcel)
(Complete a separate PS Form 1583 for EACH applicant. Spouses may
complete and sign one PS Form 1583. Two items of valid identification apply
8549 Wilshire Blvd #
to each spouse. Include dissimilar information for either spouse in appropriate
3d. ZIP + 4 ®
3b. City
3c. State
box.)
Beverly Hills
90211
A
CA
5. This authorization is extended to include restricted delivery mail for the
4. Applicant authorizes delivery to and in care of:
undersigned(s):
&
a. Name
Beverly Hills United Mailboxes
B
b. Address (No.,
8549 Wilshire Blvd #_______
street, apt./ste. no.)
A
c. City
d. State
e. ZIP + 4
Beverly Hills
90211
CA
7 a. Applicant Home Address (No., street, apt./ste. no)
6. Name of Applicant
&
A
7 b. City
7c. State
7 d. ZIP + 4
8. Two types of identification are required. One must contain a photograph
B
of the addressee(s). S ocial S ecurity cards, credit cards, and birth certificates
are unacceptable as identification. The agent must write in identifying
&
7 e. Applicant Telephone Number (Include area code)
information. S ubject to verification.
a.
9. Name of Firm or Corporation
B
1 0a. Business Address (No., street, apt./ste. no)
b.
B
1 0b. City
1 0c. State
1 0d. ZIP + 4
Acceptable identification includes
: valid driver's license or state non-driver's
1 0e. Business Telephone Number (Include area code)
identification card; armed forces, government, university, or recognized
corporate identification card; passport, alien registration card or certificate of
naturalization; current lease, mortgage or Deed of Trust; voter or vehicle
1 1 . Type of Business
registration card; or a home or vehicle insurance policy. A photocopy of your
identification may be retained by agent for verification.
If applicant is a firm, name each member whose mail is to be delivered.
1 2.
(All names listed must have verifiable identification. A guardian must list the names of minors receiving mail at their delivery address.)
B
1 3. If a COR POR ATION, Give Names and Addresses of Its Officers
1 4. If business name (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
A
imprisonment) and/or civil sanctions (including multiple damages and civil penalties).
1 5. S ignature of Agent/Notary Public
1 6. S ignature of Applicant (If firm or corporation, application must be signed
by officer. Show title.)
&
1 583,
This form on Internet at ®
December 2004 (Page 1 of 2) (7 530-01-00 0-9365)
PS Form
B

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