Mailbox Application

Mailbox Application
Renter Information
Name*
Company Name*
Physical Address*
City, State,Zip Code*
Telephone #*
Emergency Contact*
Email
example@example.com
Mail Service
Personal ($175.00)Company ($225.00)Additional Renter ($45.00)

Date*

MonthDayYear
Date
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 address order with the Postal ServiceTM 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 PS Form 1583 to the Postal Service and retains a duplicate completed signed copy at the CMRA business location. The CMRA 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 Postal Service 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.

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. Include dissimilar information for either spouse in appropriate box.)

SMART TECH AND PRINT SOLUTIONS
3a. Address to be Used for Delivery (Include PMB or# sign.) 3004 ALTONA & WELGUNST, SUITE 1 - PMB________*
ST. THOMAS VI3 00802
4. Applicant authorizes delivery to and in care of:

SMART TECH AND PRINT SOLUTIONS

3004 ALTONA & WELGUNST, SUITE1 ST.THOMAS VI 00802

5. This authorization is extended to include restricted delivery mail for the undersigned(s):
Name of Applicant*

First NameLast Name
Address of Applicant*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant's Telephone Number*
Please enter a valid phone number.Format: (000) 000-0000.
8. Two types or identifications are required. One must contain a photograph or the address (s). Social Security cards, credit cards, and birth certificates are unacceptable as identification. The agent must write in identifying information.

Subject to verification.

Acceptable identification includes a valid driver's license or state non-driver's 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 registration card; or a home or vehicle insurance policy. A photocopy of your

identification may be retained by agent for verification.
Identification 1*

Cancelof
Identification 2*

Cancelof
Signature of Applicant*

Clear
Should be Empty: