NAME OF PROJECT____________________________________________________________
ADDRESS OF PROJECT ____________________________________ DATE ______________
POST OFFICE/ZIPCODE_______________________________PROPOSED ROUTE #_______
This Project is: NEW CONSTRUCTION ___ RENOVATION ___ (If renovation, please complete
conversion request)
Estimated 1
ST
Occupancy Date: ________ 10% Occupancy: ________ Completion: _______
Delivery options will be explained by USPS representative (options shown in gray below).
Type of Project Deliveries Equipment-Type / # EQUIPMENT OPTIONS
Office Bldg (__Floors) ______ ___________________ CBU Type I (8 Del)
Shopping Mall ______ ___________________ CBU Type II (12 Del)
Strip Mall ______ ___________________ CBU Type III (16 Del)
Apts./Condos (__Floors) ______ ___________________ CBU Type IV (13 Del)
Townhouses ______ ___________________ Curb line 2/post
Single Family Homes ______ ___________________ Curb line 4/post
Trailer Park ______ ___________________ Wall mount STD 4C
Other (Specify) ______ ___________________
DEVELOPER / CONTRACTOR / OWNER RESPONSIBILITY IS AS FOLLOWS:
Location and installation of all receptacles must be approved by USPS representative.
Concrete pads for CBU’s are required to meet USPS specifications.
Concrete pads for CBU’s are installed by: Developer _X_ other __
Equipment purchased by: Developer _X_ other __
Equipment installed by: Developer _X_ other __
Equipment owned/maintained by: Developer __ other __
Keys issued to residents by: Developer _X_ USPS __ other __
Locks changed by: Developer __ USPS __ other __
Residents of single-family homes must be informed of their ongoing responsibility for keys;
box maintenance/repair, snow removal, etc.
Note: On multi-tenant delivery and/or rental situations, the building owner/manager is responsible
for lock changes. Owner/manager will handle parcels and accountable? Yes __ No __
This notice will serve as an Agreement / Letter of Consent to the Postal Service for the placement of Centralized Delivery
Equipment at the agreed upon location(s) indicated on the plat map. By signing below, I acknowledge that the contractor
options and responsibilities outlined above for receiving mail delivery service have been discussed with me.
USPS REPRESENTATIVE PROPERTY DEVELOPER/MGR/OWNER
NAME____________________________ NAME_________________________________
TITLE____________________________ TITLE_________________________________
SIGNATURE_______________________ SIGNATURE___________________________
TELEPHONE #_____________________ TELEPHONE #_________________________
DATE_____________________________ DATE_________________________________
This agreement is subject to final approval by District Operations Programs Support. Submit
completed agreement and other required attachments to the local Post Office to forward to
the Growth Management, Operations Programs at the TN District Office
MODE OF DELIVERY AGREEMENT
TENNESSEE DISTRICT