Ps Form 3615 - 2012 Mailing Permit Application And Customer Profile

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A. Applicant Information (Please print or type requested information)
Permit Imprint Authorization
®
United States Postal Service
Mailing Permit Application
(Please keep this card for your records.
1. Mail Owner (Individual or Company Name)
2. Date
and Customer Profile
Instructions available on reverse.)
Permit Number
Date Permit Issued
Issuing
Instructions available on reverse
Office
Two forms of identification are required when
3. Applicant's Signature *(See Privacy Notice below)
4. Email Address (required if known)
submitting this application. One form of ID
must contain a photograph of the applicant(s).
AIC
Application Fee Due
The applicant must enter the two ID numbers
on line 8a and line 8b which is subject to veri-
140
5. Address (Street and number, apt. or suite no., city, state, and ZIP + 4®)
fication by the postal employee completing the
$
application. Social Security cards, credit
Postmaster or Designee Signature
cards and birth certificates are not acceptable
forms of identification.
6. Other Names Under Which Company Does Business (If applicable)
7. How Can We Contact You?
Telephone
Email
Mail
Authorization for Precanceled Stamps or
Postage Evidencing Systems (Meter/PC
8a. Enter first ID number.
9. Federal Agency Cost Code (If applicable)
10. Will Present Plant Verified Drop
Postage) to Present Presorted Mail in Bulk
Shipment (PVDS)?
(Please keep this card for your records. Instructions
Yes
No
available on reverse.)
11. Contact Person
12. Telephone No. (Include area code)
8b. Enter second ID number.
Permit Number
Date Permit Issued
Issuing
Office
For Postal Service™ Use Only
B. Check Applicable Type of Permit/Authorization Requested
Permit
Date
Date
Sample
Postmaster or Designee Signature
Will you be mailing anything that is liquid, fragile, perishable, or potentially hazardous?
Number
Issued
Canceled
Approved
See DMM 601
Yes
No
1.
Permit Imprint Authorization (One time Application fee required )*
Company
Permit
First-Class® Mail
Standard Mail®
Package Services
Imprint
Business Reply Mail Authorization
2.
(Please keep this card for your records. Instructions
Precanceled Stamp Authorization*
available on reverse.)
Permit Number
Date Permit Issued
Issuing
Government Precanceled Stamped Envelope Authorization*
Office
Mailer Precanceled Postmark/Preprinted Rate Markings Authorization*
Fee Due
Unique BRM ZIP+4(s)
Preprinting of Rate Markings
Mailer Precancel Postmark
See DMM 604.3
$
3.
BRM w/Advance Deposit
Postage Evidencing System (Meter/PC Postage™) Authorization*
Account Maintenance Fee
4.
Due $
Business Reply Mail™ (BRM) Authorization**
Postmaster or Designee Signature
a. Post Office™ (Station or Branch) where BRM will be received:
(a)
b. Post Office where BRM permit number was issued and annual fee was paid, if
Merchandise Return Service Authorization
applicable:
(b)
(Please keep this card for your records. Instructions
Business Reply Mail Account Maintenance Fee (For advance deposit account)***
available on reverse.)
Date Permit Issued
Issuing
Permit Number
Office
Qualified Business Reply Mail™ (QBRM) Approved***
5.
Merchandise Return Service (MRS) Authorization (Select below)***
Fees Due
AIC
a. Type of Application
b. Return Location
*
Annual mailing fee is required to present
If Multiple Return locations are
141
presorted mail
selected, complete appropriate
Initial
Single
$
** Annual permit fee required
section on back of form.
Reapplication
Multiple
*** Annual permit and annual account
Postmaster or Designee Signature
maintenance fee required
3615,
*
PS Form
January 2012 PSN 7530-03-000-6048
Privacy Notice: Information provided may be used for marketing purposes, see our privacy policy at

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