Key

Form 1583 Sample Guide = Business Fields

= Complete fields in order to avoid
mistakes requiring re-notarization

Date Mailbox Opened Applicant's Legal Name - Photo ID Number

As Listed on IDs

State or Agency Photo ID Expiration Date

Applicant's iPostal1 Address that Issued Photo ID
+ Unique Mailbox # Select One
Select One (For USPS purposes
only. Selection will
not affect your plan

Applicant's Legal Name - As Listed on IDs Applicant's Legal Name - As Listed on IDs

Applicant's Phone Number Applicant's Email Address Address must match the
Address ID (9g), NOT the
Photo ID
Address must match the
Address ID (9g), NOT the
Photo ID Select One
✓

N/A N/A N/A N/A N/A

N/A Block 5 N/A N/A N/A

Block 10
(Not applicable) (Not applicable)
N/A N/A

N/A N/A N/A N/A

N/A N/A
Block 6 Block 11
N/A (Not applicable) N/A N/A N/A (Not applicable)

N/A N/A N/A N/A N/A N/A

N/A
[Business Business/Organization Name Business Type
Custom]ers
Only
Enter Business Address - Minor Children (Under 18yrs) only
As Registered
Applicant's Signature Business Title Date

Business Phone Number Domestic: Enter County & State Agent/Notary's Signature Date
Foreign: Enter Country

UNREGISTERED?
Business Address: Address in 2a-e can be used
Place of Registration: Enter N/A
(One business name per account)
If notarizing with a Notary Public, ensure this section is completed
 ALINA DINITA D530000949280
January 17, 2024

FL Novmeber 28, 2027

5342 CLARD RD 1257

SARASOTA FL 34233 ✔

DINITA ALINA ALINA DINITA

115 Renshaw Dr
+13865868275

115 Renshaw Dr Palm Coast FL 32164 US

Palm Coast FL 32164 US

✔

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DINITA HOSPITALITY INC CORPORATION

115 Renshaw Dr

Palm Coast FL 32164

FLAGLER COUNTY
+13865868275