United States Postal Service
Application for Delivery of Mail Through Agent
See Privacy Act Statement on Reverse
4. Applicant authorizes delivery to and in care of:
6. Name of Applicant Your legal name(s)
9. Name of Firm or Corporation Complete if firm or corporation, you
may leave blank or “N/A” if not applicable.
7a. Applicant Home Address (No., street, apt./ste. no) Your current
address or address from identification(s).
11. Type of Business
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.)
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.
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 Signature of Notary
16. Signature of Applicant (If firm or corporation, application must be signed by
officer. Show title.) Your signature(s) here.
PS Form 1583, December 2004 (Page 1 of 2) (7530-01-000-9365)
3a.Address to be Used for Delivery (Include PMB or # sign.)
110 E. Center Street #
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
List your name(s) used on all mail.
5. This authorization is extended to include restricted delivery mail for the
undersigned(s): Your signature here authorizes
MyDakotaAddress to receive and forward
restricted delivery mail.
10e. Business Telephone Number (Inclu