Fillable Mail Receiving And Forwarding From Las Vegas Sheet Template (Page 3 of 3) in pdf

United States Postal Service@

Application for Delivery of Mail Through Agent

See Privacy Act Statement on Reverse

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 iddress 6rdei with the Postal Serviceil upon termination of the agency relationship; (2) the transfer of

mlit 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 tiansfers mail; and (5) when any information required on this form changes or becomes obsolete, the

addressee(s) must file a revis6O application with the Commercial Mail Receiving Agenby (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 proviOes the original completed signed PS Form 1583 to the Postal Service and retains a duplicate completed signed copy_ at

the CMRAbusiness location. The CMftA copy of PS Form PS 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 Po_stal Service rules and

regritatioris 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.

2. Name in Which Applicant's Mail Will Be Received for Delivery to Agent.

(Complete a separate PS Form 1583 for EACH applicant. Spouses may

complete and sign one PS Form 1583. Two items of valid identification apply

to each spouse . lnclude dissimilar information for either spouse in appropriate

box.)

4. Applicant authorizes delivery to and in care of:

a. N am e

CHQ INCORPORATEI)

b. Address (No.,

street, apt./ste. no.)

2235 Flamingo Road, Suite 201G

c. City

3a.Address to be Used for Delivery (nclude PMB or# sign.)

2235 tr'Iamingo Roall, #2OlG

3d. ZIP + 4

89119-5129

5. This authorization is extended to include restricted delivery mail for the

undersigned(s):

N/A

7a. Applicant Home Address (No., street, apt./ste. no)

7b. City

7e. Applicant Telephone Number (lnclude area code)

9. Name of Firm or Corporation

10a. Business Address (No., street, apt./ste. no)

10c. State 1 0 d . ZI P + 4

10e. Business Telephone Number (lnclude area code)

1 1. Type of Business

(Att names /isfed must have verifiable identification. A guardian must list the names

Las Vegas

e.ZlP + 4

89119-5129

6. Name of Applicant

(Same as box 2)

B.Two types of identification are required. One must contain a photoglaph 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.

12. lf applicant is a firm, name each member whose mail is to be delivered.

of minors receiving mail at their delivery address.)

't b.

3c. State

7 d. Z I P + 4

13. lf a CORPORATION, Give Names and Addresses of lts Officers

14. lf 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

imprisonment)

and/or civil sanctions (including multiple damages and civil penalties).

15. Signature of AgenVNotary Public

16. Signature of Applicant (tf firm or corporation, application must be signed

by officer. Show title.)

PS Form 1583, December 2004 (Page 1 of 2) (7530-01-000-9365)

This form on Internet at

Mail Receiving And Forwarding From Las Vegas Sheet Template Page 3

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