Premium Forwarding Service (Pfs) Application printable pdf download

Premium Forwarding Service

Postal Regulatory Commission

(PFS) Application

Submitted 3/12/2007 2:28:21 pm

Instructions for completing this form are printed on the reverse of the last

PLEASE READ BEFORE YOU COMPLETE THIS FORM

Filing ID: 56002

copy (card stock) of this form. Press firmly and legibly when completing this

The Terms and Conditions governing this service are printed on the reverse of

Accepted 3/12/2007

form; you are making 3 copies. Shaded items #18 - 21 may only be

Copy 2 - Customer. Please read the reverse of this form carefully. By affixing your

completed by Postal Service™ personnel.

signature in item #14 (below) you are indicating that you understand and agree to

1. Premium Forwarding Service requested for:

the terms of this service agreement.

Applications for this service can only be accepted and processed at the Post

Individual

Entire Household

Office™, including any of its stations or branches, that serves your primary address.

3. Email Address (Optional)

2. Customer Name (Last, first, MI)

5. Temporary Address (Number, street, suite, apt., P.O. Box etc.)

4. Primary Local Address (Number, street, suite, apt., P.O. Box, etc.)

4a. For Puerto Rico Only: If address is in PR, print Urbanization Name, if

5a. For Puerto Rico Only: If address is in PR, print Urbanization Name, if

appropriate.

9. City

10. State

11. ZIP+4

6. City

7. State

8. ZIP+4

13. Temporary Contact Telephone Number, including Area Code (Plus extension if

12. Primary Contact Telephone Number(s), including Area Code (Plus

appropriate)

extension if appropriate)

14. Customer Signature

15. Start Date (MM/DD/YYYY)

16. End Date (MM/DD/YYYY)

By signing this form, you acknowledge that you agree to the

Terms and Conditions of the PFS program as printed on the

reverse of Copy 2 - Customer.

17. Upon end of PFS, indicate when you want

18. Last Shipment Date

the Post Office to resume normal mail

delivery. (Please read Instruction #17 on

reverse of Copy #4 before completing this

date.)

Application Date

Signature

(MM/DD/YYYY)

20. Type of Photo ID (Please record type of ID — e.g., Driver's License, Passport —

19. Receiving Post Office™ Name and Address (Please print or use

but do not record the number. Government-issued IDs only. Credit cards and

address stamp)

IDs issued by private companies are not acceptable forms of photo ID.)

21. Postal Service Employee (Please initial, date, and verify that payment and

enrollment fee are received.)

Total amount received for PFS: $

(Includes $10.00 nonrefundable enrollment fee)

Date Received

Initials

22. Survey Question (optional)

Please take a moment to complete our survey below. While we appreciate you taking the time to respond to our brief questions, your response is optional.

As a future alternative to enrolling at the Post Office, would you prefer to enroll in the program using the following options?

Enroll using Internet

Yes

Enroll by telephone via a toll-free number

Yes

23. Privacy Notice:

The information you provide will be used to forward your mail to a new location. Collection is authorized by 39 U.S.C. 404. Filing this form is voluntary, but we

cannot forward your mail without it. We do not disclose your information, except in the following limited circumstances: to government agencies or bodies as

required to perform official duties; to mailers, only if they already possess your old address; in legal proceedings or for service of process; to law enforcement as

needed for a criminal investigation; or to contractors who help fulfill the service. For more information on our privacy policies, see our privacy link on

Distribution: Copy 1

Post Office

8176

PS Form

, August 2006 (PSN 7530-07-000-6197)

Premium Forwarding Service (Pfs) Application

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