SCAN Form - 09/14/2017 #2

SCAN form: 
SCAN form URL: 
https://swsim.stamps.com/Label/scanform.ashx/scanform-200.png?AQAAAK61NUxs_NQIBnRU_vjyUokmivmzeVdK3Q7lyaPT9G7ohIMkTrNjlH-98iik