Cmra Form

United States Postal Service®
Application for Delivery of Mail Through Agent 1. Date

See Privacy Act Statement on Reverse 8/31/2018
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 Service™ 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. 3a.Address to be Used for Delivery (Include PMB or # sign.)
(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 4435 East Chandler Boulevard, Suite 200
box.) 3b. City 3c. State 3d. ZIP + 4®
Mildnet, Llc Phoenix AZ 85048
5. This authorization is extended to include restricted delivery mail for the
4. Applicant authorizes delivery to and in care of: undersigned(s):
a. Name
Office Evolution (Phoenix, AZ)
b. Address (No.,
street, apt./ste. no.) 4435 East Chandler Boulevard, Suite 200
c. City d. State e. ZIP + 4
Phoenix AZ 85048
6. Name of Applicant 7a. Applicant Home Address (No., street, apt./ste. no)
Ronald Gustav 31 2nd St
8.Two types of identification are required. One must contain a photograph of 7b. City 7c. State 7d. ZIP + 4
the addressee(s). Social Security cards, credit cards, and birth certificates
are unacceptable as identification. The agent must write in identifying
Mcgill NV 89318
information. Subject to verification. 7e. Applicant Telephone Number (Include area code)
a. (910) 795-1847
Passport - 03I6II957 9. Name of Firm or Corporation
Mildnet, Llc
b. 10a. Business Address (No., street, apt./ste. no)
Other - 91078618478810 31 2nd St
10b. City 10c. State 10d. ZIP + 4
Mcgill NV 89318
Acceptable identification includes: valid driver's license or state non-driver's 10e. Business Telephone Number (Include area code)
identification card; armed forces, government, university, or recognized
corporate identification card; passport, alien registration card or certificate of (910) 795-1847
naturalization; current lease, mortgage or Deed of Trust; voter or vehicle 11. Type of Business
registration card; or a home or vehicle insurance policy. A photocopy of your
identification may be retained by agent for verification.
Limited Liability Company
12. 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.)
20
13. If a CORPORATION, Give Names and Addresses of Its Officers 14. If business name (corporation or trade name) has been registered, give
name of county and state, and date of registration.
919 NORTH MARKET STREET, SUITE 950, WILMINGTON,
New Castle, DE, 19801 5421735
Warning: The furnishing of false or misleading information on this form or omission of material information may result in criminal sanctions (including fines and
imprisonment) and/or civil sanctions (including multiple damages and civil penalties).
15. Signature of Agent/Notary Public 16. Signature of Applicant (If firm or corporation, application must be signed
by officer. Show title.)
PS Form 1583, December 2004 (Page 1 of 2) (7530-01-000-9365) This form on Internet at www.usps.com®

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United States Postal Service®

Application for Delivery of Mail Through Agent 1. Date

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