POSTAL & REGISTERED MAIL PICKUP AUTHORIZATION
================================================================

Effective Date: ________________________________________________________
Place: _________________________________________________________________

================================================================

1. Parties
----------

This document is made on ____________________ (____________________) by:

Mail Recipient
Individual
Full Legal Name: _______________________________________________________
SSN / ID: ______________________________________________________________
Doc Series: ____________________________________________________________
Address: _______________________________________________________________
         _______________________________________________________________

In favor of:

Authorized Person
Individual
Full Legal Name: _______________________________________________________
SSN / ID: ______________________________________________________________
Doc Series: ____________________________________________________________
Address: _______________________________________________________________
         _______________________________________________________________

2. SUBJECT-MATTER SCHEDULE & SPECIFICATIONS
-------------------------------------------

Post Office / Pickup Location: _________________________________________
Mail Items Covered (Letters, Parcels, Registered Mail):
    ____________________________________________________________________
Authorization Valid From / Until:
    ____________________________________________________________________

3. EXECUTION & SIGNATURES
-------------------------

Mail Recipient

Signature: _____________________________________________________________

Full Legal Name: _______________________________________________________
Date: __________________________________________________________________