PS Form 1093-A – Fill Out and Use This PDF

1.

Name

of

Applicant (Last, First, MI) (include title if representing a business/organization)

2.

Email Address (required for automatic payment notifications)

3.

Name

of

Business/Organization (if applicable)

4.

PO Box Number(s)

Optional Automatic Renewal Payment — Terms and Agreement (Required for 3-month payment option)

By

initialing below

and

establishing

automatic renewal payments at

a

Post Office, I hereby authorize the U.S. Pos

®

(USPS®) to charge

my credit

card for the amount

of

my

designated

box

size

per USPS pricing on the scheduled

I have selected

(i.e.,

3,

6, or

12 months). This

charge

could

appear

on

my

credit

card statement

as

early as th

the

month prior to

the

due

date.

If

I provided

my

e-mail

address,

I understand that

I will receive

e-mail

notificatio

10 days prior to the actual credit

card charge.

I will

also

receive a

payment

due notice in my PO Box before

date. I understand

that I may

cancel

the automatic payment

option

any

time

after the initial application/payment p

complete during the business hours

at the Post Office where my box

is located. If I do not cancel

by

the 14t

prior to the next payment due date, I understand that

the

payment

will

be

charged to my credit card.

I underst

payment cannot be transacted due

to

incorrect

or obsolete

payment

information or

the

transaction wouldcreit exceed

limit of the account, or

the

bank

or

credit

card company

rejects/returns

the

payment request, my PO Box may

and any mail received after closure

would

be returned

to

the

sender. If my

PO Box is closed for nonpayment,

that

I could be

charged

a late payment fee to

reactivate

my

PO

Box

service. If there

are

any

changes

to my

number, billing address, or expiration date, I agree to notify

the Post

Office

where my box is located of these

understand that this agreement will

remain in effect until I or USPS terminates the

PO

Box service.

The USPS

updated

credit

card account information

from

the

institution

that issued the card identified

for

payment.

If

I decide

my

PO

Box,

I must

visit the Post

Office where my box is located during business hours.

(See

the

PO

Box re

information on refunds.) The USPS may terminate my participation under this

automatic payment agreement in th

provide incorrect, false, or fraudulent account information or

if

I have

any returned payment

items.

Customer Initials __________ Billing Address (associated with editcr card):

Number, Street, Suite______________________________________________________________________________________________________________________

City ______________________________________________________________________________ State

AL

®

ZIP+4 ____________________________

Application

Date