Application for Delivery of Mail Through Agent

See Reverse for Instructions, Definitions, Agreement Terms, and the Privacy Act Statement.
1. Private Mailbox (PMB) Information 8. Photo ID Information for Applicant9
1a. Date PMB Opened 1b. Date PMB Closed 8a. Applicant’s Name 8b. Applicant’s ID Number
03/25/2025 Pamela J Burk N3565432
2. Commercial Mail Receiving Agency (CMRA) Place of Business
Information 8c. Issuing Entity 8d. Expiration Date on the ID
2a. Street Address to be Used for Delivery1 California DMV 08/26/2027
901 Broadway #24210 2b. PMB #
SMB#82308

2c. City 2d. State 2e. ZIP + 4® 8e. Photo ID type (check one)
Nashville TN 37202 U.S. State/Territory/Tribal Driver’s or Nondriver’s ID Card10
3. Type of Service Requested Uniformed Service ID Passport Certificate of Naturalization
U.S. Access Card Matricula U.S. Permanent Resident
Business/Organization Use2 Residential/Personal Use3 Consular Card
NEXUS
U.S. University
Card ID Card
4. Name of Applicant 9. Address ID Information for Applicant11
4a. Last Name 4b. First Name 4c. Middle Initia 9a. Applicant’s Name
Burk Pamela J Pamela Burk
4d. Telephone Number (include area
code) 4e. Email Address 9b. Applicant’s Street Home Address1
[email protected] Po box 35
972-803-9170
9c. City 9d. State 9e. ZIP + 4 9f. Country
4f. Applicant’s Street Home Address1,4
Piedra CA 93649 United
Po box 35 States
4g. City 4h. State 4i. ZIP + 4 4j. Country 9g. Address ID type (check one) — Must Contain the Address in 9b–9f
Piedra CA 93649 United U.S. State/Territory/Tribal Driver’s or Nondriver’s ID Card10
States Current Lease Home or Vehicle Insurance Policy
4k. Is applicant a court-ordered protected Yes No Mortgage or Deed of Vehicle Registration Voter Card
individual? Trust Card
If “Yes,” you must attach a copy of the court
order.
5. Authorized Individual5 10. Photo ID Information for Authorized Individual (if applicable)9
5a. Last Name 5b. First Name 5c. Middle Initial 10a. Authorized Individual’s Name 10b. Authorized Individual’s ID
Number

5d. Telephone Number (include area 5e. Email Address 10c. Issuing Entity 10d. Expiration Date on the ID
code)

5f. Authorized Individual's Street Home Address1,6 10e. Photo ID type (check one)
U.S. State/Territory/Tribal Driver’s or Nondriver’s ID Card10
Uniformed Service ID Passport Certificate of Naturalization
5g. City 5h. State 5i. ZIP + 4 5j. Country U.S. Access Card Matricula U.S. Permanent Resident
Consular Card
U.S. University ID Card NEXUS Card
6. If Transferring PMB Mail to Another Address7… 11. Address ID Information for Authorized Individual (if applicable)11
6a. Street Address Mail Is Transferred To1 11a. Authorized Individual’s Name
1814 N Memorial Way
6c. State 6d. ZIP + 46e. Country11b. Authorized Individual’s Street Home Address1
6b. City 77007 USA
TX
Houston
6f. Telephone Number (include area 6g. Email Addresss 11c. City 11d. State 11e. ZIP + 11f.
code) [email protected] 4 Country
877-214-0121
7. Business/Organization Information 11g. Address ID type (check one) — Must Contain the Address in 11b–11f
7a. Name of Business/Organization 7b. Type of Business U.S. State/Territory/Tribal Driver’s or Nondriver’s ID Card10
SnapMailbox LLC Current Lease Home or Vehicle Insurance Policy
Mortgage or Deed of Vehicle Registration Voter Card
Trust Card
7c. Business Street Address1 12. Exceptions for Additional Recipients of Mail13
1814 N Memorial Way
14
7e. State 7f. ZIP + 4 7g. Country 13a. Signature of Applicant 13b. Date
7d. City
Houston TX 77007 USA

15
7h. Telephone Number (include area 7i. Place of Registration8 14a. Signature of Witness 14b. Date
code) Newcastle Delaware
877-214-0121
Instructions and Footnotes
1 Include house number, street, and apartment/suite number if applicable.

2 For Business/Organization Use, complete item 7.

3 For Residential/Personal Use, complete a separate PS Form 1583 for each adult using this PMB.

4 Address must match document provided in item 9b.

5 The Applicant authorizes mail to be collected by the individual noted in item 5.

6 Address must match document provided in item 11b.

7 Complete item 6 if the mail addressed to this PMB is to be transferred, mailed, shipped, or emailed to another address.

8 The place of registration is the county and state (if domestic), or the country (if foreign).

9 Two types of identification are required for both the Applicant and, if listed, the Authorized Individual. One ID must be a government-issued photo ID.
The second must confirm the Applicant’s or Authorized Individual’s address listed on this form. The acceptable types of photo ID are listed in items 8e
and 10e. Attach a copy of the photo and address ID documents.

10 Although the driver’s/nondriver’s ID is listed in 8e and 9g as an option for both the Applicant’s photo ID and address ID, it may be used for only one of
the IDs (either photo ID or address ID), not for both.
The acceptable types of address verification are listed in items 9g and 11g. Attach a copy of the photo and address ID documents.
11
Although the driver’s/nondriver’s ID is listed in 10e and 11g as an option for both the Authorized Individual’s photo ID and address ID, it may be used
12 for only one of the IDs (either photo ID or address ID), not for both.
For Business/Organization Use: List members who will be receiving mail at this PMB. Each person listed must, upon request, present two forms of valid
13 ID to the Postal Service. For Residential/Individual Use: A parent or guardian may receive the mail of a minor by listing the minor’s name — the
minor’s ID is not required.

By signing this form, the applicant certifies the following — for Business/Organization Use, an officer must sign the application and provide his or her
14 title: I certify that all information furnished on this form is accurate, truthful, and complete. I understand that anyone who furnishes false or misleading
information on this form or omits information requested on this form may be subject to criminal and/or civil penalties, including fines and
imprisonment.
The witness can be the agent, an authorized employee, or a Notary Public

15

Definitions: at the home or business address listed in items 4f or 7c, and that the
Agent: The Commercial Mail Receiving Agency (CMRA). Authorized identifications listed in items 8–11 are valid. The agent must complete items
employee: An employee of the CMRA who is authorized to act on the 2a–2e, and items 14a and 14b if necessary (i.e., if the agent is the witness),
CMRA’s behalf. Authorized individual: A person who is authorized to pick and the customer must complete all the other items.
up mail for the PMB holder. Privacy Act Statement: Your information will be used to administer the
Agreement: In consideration of delivery of my mail or our firm’s mail to Commercial Mail Receiving Agency (CMRA) application, enrollment, and
the agent named on Page 1, the applicant and agent agree: (1) the fulfillment processes, to verify your identity when applying for service via a
applicant or the agent must not file a change of address order with the CMRA, to ensure proper and secure delivery of mail to the correct recipient,
Postal Service™ upon termination of the agency relationship; (2) the and to permit delivery of your mail to your authorized agent. Collection is
transfer of mail to another address is the responsibility of the applicant authorized by 39 USC 401, 403, and 404. Supplying the information is
and the agent; (3) all mail delivered to the agency under this authorization voluntary, but if not provided, we will not be able to fulfill your request for
must be prepaid with new postage when redeposited in the mails; (4) the delivery of mail through an agent. We do not disclose your information
agent must provide to the Postal Service all addresses to which the without your consent to third parties, except for the following limited
agency transfers mail; and (5) when any information required on this form circumstances: incident to legal proceedings involving the Postal Service; for
changes or becomes obsolete, the applicant must file an updated law enforcement purposes; to a congressional office on your behalf; to agents
application with the agent or contractors when necessary to fulfill a business function; to a U.S. Postal
NOTE: The applicant must execute this form in the presence of the agent, Service auditor; to labor organizations as required by applicable law; to
his or her authorized employee, or a notary public. The agent uploads the government agencies in connection with decisions as necessary; to agencies
original completed signed PS Form 1583 to the Postal Service’s CMRA and entities for financial matters; and for customer service purposes. In
Customer Registration Database and retains the completed signed copy at addition, information may be disclosed for the purpose of identifying an
the CMRA business location. The CMRA copy of PS Form 1583 must at all address as an address of an agent to whom mail is delivered on behalf of
times be available for examination by the postmaster (or designee) and other persons. However, this specific routine use does not authorize the
the Postal Inspection Service. The applicant and the agent agree to disclosure of the identities of persons on behalf of whom agents receive mail.
comply with all applicable Postal Service rules and regulations relative to All routine uses are subject to the following exception: Information
delivery of mail through an agent. Failure to comply will subject the concerning an individual who has filed an appropriate protective court order
agency to withholding of mail from delivery until corrective action is with the application will not be disclosed except pursuant to the order of a
taken. court of competent jurisdiction and subject to the approval of the USPS
This application may be subject to verification procedures by the Postal General Counsel. For more information on our privacy policies, visit
Service to confirm that the applicant resides or conducts business www.usps.com/privacypolicy.

Greensboro IS R. KIM
Witness my signature and official seal. Notary Public in and for the STATE OF , Official Seal: B
Guilford 29 day of March 25 NN
AL

COUNTY OF . On this , 20 ,
DE

STATE
L

the applicant, who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed
to this application, appeared before me, and did personally sign the application. OF
NORTH CAROLINA
Signature of Notary Public My commission expires:
NOTARY
PUBLIC
TY
GU

08/19 27 IL N
FO
20
RD COU