Cleveland Redirect Service Application Form

PLEASE PRINT THIS APPLICATION, FILL IT OUT COMPLETELY,
AND FAX OR MAIL IT TO OUR OFFICES AT:

Cleveland Redirect Service


Application for Delivery of Mail Through Agent
U.S. Postal Service Form 1583

(1) Date: __________
In consideration of delivery of my or our mail to the agent named below, the addressee and agent agree that: (1) the Postal Service will not forward my or our mail on a change of address order upon termination of this agency relationship; (2) the forwarding or return of my or our mail is the responsibility of the agent; and (3) all mail, including letters and other first class mail, delivered to the agent under this authorization must be prepaid with the new postage when re-deposited in the mails.

NOTE: This publication must be executed in duplicate by applicant in the presence of the agent, his authorized employee or a notary public. A signed copy will be kept on file by the agent in such manner that it is at all times available for examination by postal representatives.

To: Postmaster

PRIVACY ACT: The collection of this information is authorized by 39 USC'403,404. It serves as the written authority for the delivery of mail other than as addressed. As a routine use, this information may be disclosed to an appropriate law enforcement agency for investigative or prosecution proceedings, to a congressional office at your request, to a labor organization as required by the NLRA, and where pertinent, in a legal proceeding to which the Postal Service is a party. Completeion of this form is voluntary, however, if this information is not provided the mail will be withheld from delivery to the agent and delivered to the addressee, or if the address of the addressee is that of the agent, returned to the sender.

(2)  Mail Addressed to (Name, Address and ZIP Code)

     ______________________________________________________________________________

(3)  Deliver to and in care of  (Name, Address and ZIP Code of agent)

     ______________________________________________________________________________

(4)  Name of applicant

     ______________________________________________________________________________

(4a) Home address (Number, street and ZIP code)

     ______________________________________________________________________________

(5)  Name of firm or corporation

     ______________________________________________________________________________

(5a) Business address  (Name, street, and ZIP code)

     ______________________________________________________________________________

(6)  Kind of business

     ______________________________________________________________________________

(7)  If address is a FIRM, name each member whose mail is to be delivered

     ______________________________________________________________________________

(8)  If a CORPORATION, give names and addresses of its officers

     ______________________________________________________________________________

(9)  Reference (Name, address, and ZIP code)

     ______________________________________________________________________________

(10) Reference (Name, address, and ZIP code)

     ______________________________________________________________________________

(11) If business name of the address (Corporation or Trade Name) has been

     registered, give name of country and state, and date of registration.

     ______________________________________________________________________________

(12) Signature of agent

     ______________________________________________________________________________

(13) Signature of applicant (If firm or corporation,application must be signed

     by officer.  Show title.)

     ______________________________________________________________________________
This document is an exact fascimile of PS Form 1583.

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