Application for Delivery of Mail Through Agent

First name*

Name in which applicant's mail will be received for delivery to agent.
Last name*
Address to be Used for Delivery (include PMB or # sign)*
Street Address City State / Province / Region ZIP / Postal Code

Applicant authorizes delivery to and in care of:
Full Name*
First Last
Address*
Address (No., street, apt./ste. no.) City State ZIP Code
This authorization is extended to include restricted delivery mail for the undersigned(s):*

Two types of identification are required. One must contain a photograph 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.
Acceptable identification includes: 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.
Upload Files*
Maximum 10 files are allowed.
Drop files here or

Max. file size: 125 MB, Max. files: 10.

Name of Firm or Corporation
Type of Business
Business Address
Business Address (No., street, apt./ste. no) City State ZIP Code
Business Telephone Number (Include area code)

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

All names listed must have verifiable identification. A guardian must list the names of minors receiving mail at their delivery address.
If a CORPORATION, Give Names and Addresses of Its Officers
Name Address
If business name (corporation or trade name) has been registered, give name of county and state, and date of registration.
County State Date
Signature of Agent/Notary Public*
Signature of Applicant*
If firm or corporation, application must be signed by officer. Show title.

Applicant authorizes delivery to and in care of:

Name	Address

County	State	Date