Fillable Printable Sample Postal Service Address Change Form

Sample Postal Service Address Change Form

SECTION A: REASON FOR SUBMISSION — Check one box.

SECTION B: TO BE COMPLETED BY LICENSEE

NOTE TO LICENSEE: Business records must be maintained at your licensed and approved business address.

SECTION C: TO BE COMPLETED BY POSTAL REPRESENTATIVE

REQUEST FOR MAILING ADDRESS

Licensee completes Section B, Postal Representative completes Section C

CHANGE OF PREVIOUSLY APPROVED MAILING ADDRESS

Licensee completes Section B

BUSINESS NAME OL NUMBER

BUSINESS ADDRESS CITY STATE ZIP CODE

MAILING ADDRESS (IF CHANGING MAILING ADDRESS, LIST NEW ADDRESS) CITY STATE ZIP CODE

FORMER MAILING ADDRESS CITY STATE ZIP CODE

PRINTED NAME OF LICENSEE TITLE

SIGNATURE OF LICENSEE DATE

POSTAL SERVICE VERIFICATION OF NO MAIL DELIVERY SERVICE

OR CHANGE OF MAILING ADDRESS

INSTRUCTIONS: This form is to be used only if regular postal service is not available. Submit completed form to your local

Inspector.

A Public Service Agency

OL 4000 (REV. 8/2005) WWW

The above-identified business is requesting permission from the Department of Motor Vehicles to utilize a

mailing address different than their approved business address. Please check the appropriate box regarding

mail delivery at the business address listed in Section B:

Rural

Vandalism reported to U. S. Post Office

Theft reported to U. S. Post Office

Not a deliverable address (explain below)

_____________________________________________________

U.S. POSTMASTER’S STAMP

UNITED STATES POST OFFICE ADDRESS CITY STATE ZIP CODE AREA CODE/TELEPHONE NUMBER

PRINTED NAME OF POSTAL REPRESENTATIVE TITLE

SIGNATURE OF POSTAL REPRESENTATIVE DATE