Form 1583

United States Postal Service
Application for Delivery of Mail Through Agent

See Privacy Act Statement on Reverse
1. Date
In consideration of delivery of my or our (firm) mail to the agent named below, the addressee and agent agree:
(1) the addressee or the agent must not file a change of address order with the Postal Servicea upon termination
of the agency relationship; (2) the transfer of mail to another address is the responsibility of the addressee and
the agent; (3) all mail delivered to the agency under this authorization must be prepaid with new postage when
redeposited in the mails; (4) upon request the agent must provide to the Postal Service all addresses to which
the agency transfers mail; and (5) when any information required on this form changes or becomes obsolete, the
addressee(s) must file a revised application with the Commercial Mail Receiving Agency (CMRA).
NOTE: The applicant must execute this form in duplicate in the presence of the agent, his or her authorized
employee, or a notary public. The agent provides the original completed signed PS Form 1583 to the Postal
Service and retains a duplicate completed signed copy at the CMRA business location. The CMRA copy of PS
Form PS 1583 must at all times be available for examination by the postmaster (or designee) and the Postal
Inspection Service. The addressee and the agent agree to comply with all applicable Postal Service rules and
regulations relative to delivery of mail through an agent. Failure to comply will subject the agency to withholding
of mail from delivery until corrective action is taken.
This application may be subject to verification procedures by the Postal Service to confirm that the applicant
resides or conducts business at the home or business address listed in boxes 7 or 10, and that the identification
listed in box 8 is valid.
2. Name in Which Applicant's Mail Will Be Received for
Delivery to Agent
(Complete a separates Form 1583 for EACH applicant.
Spouses may complete and sign one PS Form 1583.
Two items of valid identification apply to each spouse.
Include dissimilar information for either spouse in
appropriate box.)
ADDHIE YP PUTRA, SH
4. Applicant authorizes delivery to and in care of:
(Name, Address and ZIP Code of Agent)
Eastbiz Corporation
2972 Columbia St.
Torrance, CA 90503
6. Name of Applicant
ADDHIE YP PUTRA, SH
8.Two types of identification are required. One must
contain a photograph of the addressee(s). Social
Security cards, credit cards, and birth certificates are
unacceptable as identification. The agent must write in
identifying information. Subject to verification.
.
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3. Address to Be Used for Delivery Including ZIP + 4

2220 Meridian Blvd O8346
Minden, NV, 89423
11407 SW Amu St. O8346
Tualatin, OR, 97062
3503 Jack Northrop Ave O8346
Hawthorne, CA, 90250
5. This Authorization Is Extended to Include Restricted
Delivery Mail for the Undersigned(s)
7. Applicant Home Address

JL. BUNGA MAWAR XXI KEL. PB SELAYANG II
KEC. MEDAN SELAYANG (PERUMAHAN DINAS
KEHAKIMAN)
KOTA MEDAN, , 20131
Indonesia
Telephone: 6282360098141
8a.
.
8b.
.
Acceptable identification includes: valid driver's license
or state non-driver's identification card; armed forces,
government, university or recognized corporate
identification card; passport or alien registration card or
certificate of naturalization; current lease, mortgage or
Deed of Trust; voter or vehicle registration card; or a
home or vehicle insurance policy. A photocopy of your
identification may be retained by agent for verification.
9. Name of Firm or Corporation

.
10. Business Address (Number, street, city, state, ZIP
Code and Country)
.
.
.
. Telephone number: (
)
11. Kind of business

.
12. If applicant is a firm, name each member whose mail is to be delivered. (All names listed must have verifiable
identification. A guardian must list the names of minors receiving mail at their delivery address.)
.
.
.
.
13. If a CORPORATION, Give Names and Addresses of 14. If Business name (corporation or trade name) has
Its Officers
been registered, give name of county and state, and
.
date of registration.
.
.
.
.
.
.
Warning: The furnishing of false or misleading information on this form or omission of material information may
result in criminal sanctions (including fines and imprisonment) and/or civil sanctions (including multiple damages
and civil penalties).
15. Signature of Agent/Notary Public
16. Signature of Applicant (If firm or corporation,
.
application must be signed by officer. Show title.)
.
ADDHIE YP PUTRA, SH
.
.
.
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Form 1583

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United States Postal Service

Application for Delivery of Mail Through Agent

3. Address to Be Used for Delivery Including ZIP + 4

7. Applicant Home Address

9. Name of Firm or Corporation

11. Kind of business

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