Application for Mail Delivery
Checks MUST be in US funds.
Personal checks are welcome.
We're sorry, but we do not accept credit cards.

This form should be mailed to:

Mail Forwarding Services
P.O. Box 190
Jefferson OR 97352-0190

Name of Applicant:              
Persons Receiving Mail:     

Forwarding Address:            

Emergency Phone Number:

Mother's Maiden Name:    
(to be used as your "code word" for address changes)
E-Mail Address:*                
(A note about e-mail addresses: We will never use your e-mail address for anything other than notifying you about your mail, or to clarify an address.  
We will not use it for any other purpose, nor will we share it with anyone else, for any reason.  We abhor spam, and absolutely will not contribute to it!)

Please Forward our mail: (Please Check One) (You can change this anytime, as needed)

Twice Monthly
Only On Request

Enclosed: (Please Check One)

$70.00 (3 Months @ $55 & $15.00 Postage = $70.00)
$105.00 (6 Months @ $90 & $15.00 Postage = $105.00)
$165.00 (1 Year @ $150 & $15.00 Postage = $165.00)
Other (Note Enclosed)

Amount Enclosed:

Signature/date:___________________________________________________ / ____________________

Please fill out, print this form, and mail it to:

Mail Forwarding Services
PO Box 190
Jefferson, OR 97352-0190

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