Address Integrity Application

Address Integrity Application

This application collects the information required to complete your USPS mail authorization: https://about.usps.com/forms/ps1583.pdf and facilitate mail service. By submitting this application, you also acknowledge and agree to the terms of our Customer Agreement: https://addressintegrity.com/#customer-agreement
Name

First NameMiddle InitialLast Name
Date of Birth

MonthDayYear
Date
Telephone Number (include area code)
Format: (000) 000-0000.
Primary Email Address
example@example.com
Email Address for Scanned Mail
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Type of Service Requested
Is applicant a court-ordered protected individual? If "Yes", you must attach a copy of the court order.
Plan preference
Name of Business/Organization
DBA, Trade Name, or Alternate Mail Name
Entity Type
Type of Business
Industry / Primary Activity
One-sentence business description
Briefly describe what this business does.
Current Business Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Telephone Number (indude area code)
Format: (000) 000-0000.
Place of Registration (County, State)
Country (if foreign)
Photo ID Information for Applicant

Please provide a valid, unexpired government-issued photo ID. This must match the photo ID shown during the required video verification call. You may not use the same driver’s license for both ID requirements.
Photo ID Upload

Please upload a clear, legible copy of your Photo ID. Accepted file types: PDF, JPG, JPEG, or PNG.
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Applicant's Name
Applicants ID Number
Issuing Entity
Examples: Indiana BMV, U.S. Department of State, University
Expiration Date on the ID
Photo ID type (check one)
Address ID Information for Applicant

USPS requires a separate address-verification document in addition to your photo ID. This document must confirm your current residential or business address, cannot be the same ID used for Item 8, and must match what is shown during the required video verification call.
Address ID Upload

Please upload a clear, legible copy of your Address ID. Accepted file types: PDF, JPG, JPEG, or PNG.
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Applicant's Name
Applicant's Street Home Address
City

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
9g. Address ID type (check one) - Must Contain the Address in 9b-9f
SIGNATURE OF APPLICANT (USPS Form 1583, Box 13a): By signing below, I certify that all information furnished on this USPS Form 1583 is accurate, truthful, and complete to the best of my knowledge. I authorize Address Integrity Indiana LLC, the Commercial Mail Receiving Agency (CMRA) named on this form, to receive and process mail on my behalf at the address shown in Section 2. I understand that anyone who furnishes false or misleading information on this form, or who omits information requested on this form, may be subject to criminal and/or civil penalties under federal law, including fines and imprisonment under 18 U.S.C. § 1001. For business or organization use: as the authorized signer of the firm or organization identified in Section 7, I represent that I have full authority to bind the firm or organization to this Form 1583 and to receive mail on its behalf at the CMRA address.
CUSTOMER AGREEMENT ACKNOWLEDGMENT: In addition to the USPS Form 1583 certification above, my signature also binds me to the Address Integrity Customer Agreement, which governs my use of the CMRA mailbox service. The full Customer Agreement is available at https://addressintegrity.com/#customer-agreement and is incorporated into this signature by reference. By signing, I am agreeing to pay $20 per month (or $200 per year) per Account, with the subscription auto-renewing until I cancel and a requirement of six months' written notice to cancel. I understand that each Account covers one LLC, one authorized signer, and one delivery email address, and that any additional person or LLC who needs to receive mail at this address requires their own separate Account at $20 per month each. I understand that mail not addressed to my registered LLC or its registered authorized signer is rejected and returned to sender unopened. I understand that my address is not active until both my video verification call and my first payment are complete.
13b. Date

MonthDayYear
Date
Should be Empty:

Photo ID Information for Applicant

Address ID Information for Applicant