Box 1: Date (Month/Day/Year).

Box 2: Your Personal Name.

Box 3: Your Delaware Business Incorporators, Inc. address which is [YOUR COMPANY NAME] 3422 Old Capitol Trail, [Suite or PMB # to be assigned], Wilmington, DE 19808.

Box 4: Enter Delaware Business Incorporators, Inc. address which is 3422 Old Capitol Trail, Suite 700, Wilmington, DE 19808.

Box 5: Write “Yes” If you would like us to accept “Restricted Delivery Mail” for you. Write “No” If you would like us not to accept “Restricted Delivery Mail” for you. Restricted Delivery Mail is mail that can only be delivered to the addressee or to an authorized agent. Please note that even if you write “Yes” we may only accept restricted delivery mail when arranged in advanced by you.

Box 6: Your Personal Name.

Box 7: Your home (physical) address and phone number

Box 8: COLOR photo copy two (2) ID documents:

• Armed Forces, government, university or recognized corporate identification card
• Passport, alien registration card or certificate of naturalization
• Current lease, mortgage or Deed of Trust
• Voter or vehicle registration card
• Home or vehicle insurance policy

Box 9: Name of Your Firm or Corporation (This is for business accounts only).

Box 10: Your business address and phone number (This is for business accounts only.) This is the address we will forward your mail to.

Box 11: Kind of Business (This is for business accounts only.)

Box 12: Name of authorized mail recipients (additional names). Each person must submit identifications and be added to your online acccount as "additional names" (Only for business accounts).

Box 13: Name and Address of officers or business owners (Only for business accounts).

Box 14: Name of Registration, Address of registration. Phone of Registration (only for business accounts)

Box 15: Signature and Stamp/Seal of Notary Public. The e-notary service will collect your IDs and forward to us along with the notarized PS 1583 form.

Box 16: Your original signature. This is required.

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