MM6(E) REQUEST FOR THE RECORDING OF A LIMITATION OF THE LIST OF GOODS AND SERVICES For use by the holder For use by the Office This request contains the following number of continuation sheets: Office s reference: Holder s reference: INTERNATIONAL REGISTRATION NUMBER(S) (this form may be used for several international registrations in the name of the same holder, provided that the same limitation applies to all designated Contracting Parties or to the same designated Contracting Parties for each of the international registrations concerned) NAME OF THE HOLDER (as recorded in the International Register) APPOINTMENT OF A (NEW) REPRESENTATIVE (only complete this item if you are appointing a (new) representative) Name: Address: Telephone: E-mail address: Fax: By providing an e-mail address, any further correspondence from the International Bureau related to this/these international registration(s) will be sent only electronically and, therefore, you will no longer receive any paper correspondence. Likewise, any further correspondence from the International Bureau related to other international applications or international registrations for which the same e-mail address has been, or will be, provided will also be sent only electronically. Please note that, for the purpose of electronic communication, there can be only one e-mail address recorded per each international registration. SIGNATURE OF THE HOLDER APPOINTING THE ABOVE (NEW) REPRESENTATIVE MM6(E) January 2017 151
MM6(E) : : : ( ) () () () () (): (): : : : () MM6(E) January 2017 151
CONTRACTING PARTIES (check only one box) (a) the limitation of the list of goods and services indicated in item 5(a) and/or 5(b) is to be recorded for all the Contracting Parties designated in the international registration(s) indicated in item 1; or (b) the limitation of the list of goods and services indicated in item 5(a) and/or 5(b) is to be recorded for the designated Contracting Parties indicated below: MM6(E) January 2017 152
(1 ) (a) (b) 5 (a)/ 5 (b) 1 ; 5 (a)/ 5 (b) : MM6(E) January 2017 152
GOODS AND SERVICES NOTE: Any class covered by the international registration(s)indicated in item 1 that is not mentioned below remains as recorded in the International Register: if you want to request the recording of a limitation for one particular class in respect of the designated Contracting Parties mentioned in item 4, please provide the relevant class number and the complete new limited list of goods and services of this class under item (a); however, if you want to delete one or more entire classes in respect of those Contracting Parties, please indicate the class number(s) under item (b). You can find indications of terms of goods and services that are pre-accepted by the International Bureau in the Madrid Goods & Services Manager (MGS) at www.wipo.int/mgs/. Please make consistent use of a semicolon (;) to clearly separate the goods and services indications in your list, e.g.: 09 Scientific, optical and electronic apparatus and instruments; screens for photoengraving; computers. 35 Advertising; compilation of statistics; commercial information agencies. Please use font or Times New Roman, size 12 pt, or above. (a) If the limitation concerns changes in a given class, please provide below the relevant class number and the complete new limited list of goods and services of this class (instead of the goods or services that you wish to delete from the currently recorded list). It is important to provide clear information on the remaining scope, to ensure correct recording of the limitation in the International Register. The new limited list will be recorded for the Contracting Parties indicated in item 4. Example 1: If the international registration contains, in class 25, clothing; footwear; headgear and you want to limit certain designations to clothing and headgear, you should indicate that the new list in respect of those designations is clothing; headgear. Example 2: If you want to keep certain footwear, you should clearly indicate the remaining scope, including the kind of footwear you want to keep in the designation; for instance clothing; leather shoes, leather boots, leather sandals; headgear. Example 3: If you want to limit footwear to sandals only, you could indicate that the new list is clothing; sandals; headgear. Example 4: If you want to exclude sandals from footwear, you could indicate that the new list is clothing; footwear, except sandals; headgear. 15 Guiters; Organs (b) If an entire class is to be deleted, please indicate only the class number: (NOTE: If a class number is indicated here, it will be understood that the designation of the Contracting Parties indicated in item 4 no longer contains this class. Any class mentioned under item 5(a), above, must not be indicated here.) If the space provided above is not sufficient, check the box and use a continuation sheet. MM6(E) January 2017 153
: 1 4 (a); 4 1 (b) Madrid Goods & Services Manager (MGS)www.wipo.int/mgs/ ; 09 Scientific, optical and electronic apparatus and instruments; screens for photoengraving; computers. 35 Advertising; compilation of statistics; commercial information agencies. Courier New Times New Roman 12 (a) 4 1: 25 clothing; footwear; headgear clothing headgear 2: footwear footwear leather shoes, leather boots, leather sandals; 3: Footwear sandals 4: Footwear sandals footwear, except sandals; 15 Guiters; Organs (b) : (: 4 5(a)) MM6(E) January 2017 153
SIGNATURE BY THE HOLDER AND/OR HIS REPRESENTATIVE Holder (as recorded in the International Register) By signing this form, I declare that I am entitled to sign it under the applicable law: Name: Signature: Representative of the holder (as recorded in the International Register or herein appointed) By signing this form, I declare that I am entitled to sign it under the applicable law: Name: Signature: OFFICE OF THE CONTRACTING PARTY OF THE HOLDER PRESENTING THE REQUEST (where this request is presented through an Office) Name of the Office: Name and signature of the official signing on behalf of the Office: By signing this form, I declare that I am entitled to sign it under the applicable law: Name and e-mail address of the contact person in the Office: MM6(E) January 2017 154
() () (): : (): : () : : : MM6(E) January 2017 154
FEE CALCULATION SHEET (a) INSTRUCTIONS TO DEBIT FROM A CURRENT ACCOUNT The International Bureau is hereby instructed to debit the required amount of fees from a current account opened with the International Bureau (if this box is checked, it is not necessary to complete (b)). Holder of the account: Account number: Identity of the party giving the instructions: (b) AMOUNT OF FEES Amount (177 Swiss francs) x (per international registration mentioned in item 1) Grand total (Swiss francs) (c) METHOD OF PAYMENT Identity of the party effecting the payment: Payment received and acknowledged by WIPO Payment made to WIPO bank account IBAN No. CH51 0483 5048 7080 8100 0 Crédit Suisse, CH-1211 Geneva 70 Swift/BIC: CRESCHZZ80A Payment made to WIPO postal account (within Europe only) IBAN No. CH03 0900 0000 1200 5000 8 Swift/BIC: POFICHBE WIPO receipt number Payment identification Payment identification dd/mm/yyyy dd/mm/yyyy MM6(E) January 2017 155
(a) ( (b)) : : : (b) (177 ) x ( 1 ) () (c) : WIPO WIPO IBAN No. CH51 0483 5048 7080 8100 0 Crédit Suisse, CH-1211 Geneva 70 Swift/BIC: CRESCHZZ80A WIPO () IBAN No. CH03 0900 0000 1200 5000 8 Swift/BIC: POFICHBE WIPO // // MM6(E) January 2017 155
CONTINUATION SHEET No:... of... MM6(E) January 2017 156
No:... of... MM6(E) January 2017 156
REQUEST FOR THE RECORDING OF A RENUNCIATION MM7(E) For use by the holder For use by the Office This request contains the following number of continuation sheets: Office s reference: Holder s reference: INTERNATIONAL REGISTRATION NUMBER(S) (this form may be used for several international registrations in the name of the same holder, provided that designated Contracting Parties in respect of which the international registration is renounced are the same for each of the international registrations concerned) NAME OF THE HOLDER (as recorded in the International Register) APPOINTMENT OF A (NEW) REPRESENTATIVE (only complete this item if you are appointing a (new) representative) Name: Address: Telephone: Fax: E-mail address: By providing an e-mail address, any further correspondence from the International Bureau related to this/these international registration(s) will be sent only electronically and, therefore, you will no longer receive any paper correspondence. Likewise, any further correspondence from the International Bureau related to other international applications or international registrations for which the same e-mail address has been, or will be, provided will also be sent only electronically. Please note that, for the purpose of electronic communication, there can be only one e-mail address recorded per each international registration. SIGNATURE OF THE HOLDER APPOINTING THE ABOVE (NEW) REPRESENTATIVE CONTRACTING PARTIES The renunciation concerns the following designated Contracting Parties: MM7(E) January 2017 157
MM7(E) : : : ( ) () () () () (): (): : : : () : MM7(E) January 2017 157
SIGNATURE BY THE HOLDER AND/OR HIS REPRESENTATIVE Holder Representative of the holder (as recorded in the International Register) (as recorded in the International Register or herein appointed) By signing this form, I declare that I am entitled to sign it under the applicable law: By signing this form, I declare that I am entitled to sign it under the applicable law: Name: Name: Signature: Signature: OFFICE OF THE CONTRACTING PARTY OF THE HOLDER PRESENTING THE REQUEST (where this request is presented through an Office) Name of the Office: Name and signature of the official signing on behalf of the Office: By signing this form, I declare that I am entitled to sign it under the applicable law: Name and e-mail address of the contact person in the Office: MM7(E) January 2017 158
() () (): (): : : () : : : MM7(E) January 2017 158
CONTINUATION SHEET No:... of... MM7(E) January 2017 159
No:... of... MM7(E) January 2017 159
REQUEST FOR THE RECORDING OF A CANCELLATION OF THE INTERNATIONAL REGISTRATION MM8(E) For use by the holder For use by the Office This request contains the following number of continuation sheets: Office s reference: Holder s reference: INTERNATIONAL REGISTRATION NUMBER(S) (this form may be used for several international registrations, provided that all registrations concerned are the subject of a total cancellation, as provided for in item 4(a)) NAME OF THE HOLDER (as recorded in the International Register) APPOINTMENT OF A (NEW) REPRESENTATIVE (only complete this item if you are appointing a (new) representative) Name: Address: Telephone: Fax: E-mail address: By providing an e-mail address, any further correspondence from the International Bureau related to this/these international registration(s) will be sent only electronically and, therefore, you will no longer receive any paper correspondence. Likewise, any further correspondence from the International Bureau related to other international applications or international registrations for which the same e-mail address has been, or will be, provided will also be sent only electronically. Please note that, for the purpose of electronic communication, there can be only one e-mail address recorded per each international registration. SIGNATURE OF THE HOLDER APPOINTING THE ABOVE (NEW) REPRESENTATIVE MM8(E) January 2017 160
MM8(E) : : : ( 4 (a) ) () () () () (): (): : : : () MM8(E) January 2017 160
GOODS AND SERVICES (check either (a) or (b)) (a) or (b) TOTAL CANCELLATION (the cancellation is to be recorded for all goods and services covered by the international registration(s) indicated in item 1), PARTIAL CANCELLATION (the cancellation affects only some of the goods and services covered by the international registration(s) indicated in item 1) NOTE: Any class, covered by said registration(s), which is not mentioned below remains as recorded in the International Register. You can find indications that are pre-accepted by the International Bureau in the Madrid Goods & Services Manager (MGS) at www.wipo.int/mgs/. Please make consistent use of a semicolon (;) to clearly specify the goods and services indications in your list, e.g.: 09 Scientific, optical and electronic apparatus and instruments; screens for photoengraving; computers. 35 Advertising; compilation of statistics; commercial information agencies. Please use font Courier New or Times New Roman, size 12 pt, or above. (i) Entire class(es), if any, to be cancelled (specify only the number(s) of the class(es) concerned), and/or (ii) If the cancellation affects only some of the goods and services in a given class, please provide below the relevant class number and the complete new list of goods and services. This new list will replace the currently recorded list for such class in the International Register (in other words, do not just indicate the goods or services that you wish to delete from the currently recorded list): If the space provided above is not sufficient, check the box and use a continuation sheet MM8(E) January 2017 161
((a)(b)) (a) ( 1 ), (b) ( 1 ) : 1 Madrid Goods & Services Manager (MGS)www.wipo.int/mgs/ ; 09 Scientific, optical and electronic apparatus and instruments; screens for photoengraving; computers. 35 Advertising; compilation of statistics; commercial information agencies. Courier New Times New Roman 12 (i) ()/ (ii) : MM8(E) January 2017 161
SIGNATURE BY THE HOLDER AND/OR HIS REPRESENTATIVE Holder (as recorded in the International Register) By signing this form, I declare that I am entitled to sign it under the applicable law: Name: Signature: Representative of the holder (as recorded in the International Register or herein appointed) By signing this form, I declare that I am entitled to sign it under the applicable law: Name: Signature: OFFICE OF THE CONTRACTING PARTY OF THE HOLDER PRESENTING THE REQUEST (where this request is presented through an Office) Name of the Office: Name and signature of the official signing on behalf of the Office: By signing this form, I declare that I am entitled to sign it under the applicable law: Name and e-mail address of the contact person in the Office: MM8(E) January 2017 162
() () (): : (): : () : : : MM8(E) January 2017 162
CONTINUATION SHEET No:... of... MM8(E) January 2017 163
No:... of... MM8(E) January 2017 163
MM9(E) REQUEST FOR THE RECORDING OF A CHANGE IN THE NAME OR ADDRESS OF THE HOLDER OR, WHERE THE HOLDER IS A LEGAL ENTITY, FOR THE RECORDING TO INTRODUCE OR CHANGE INDICATIONS CONCERNING ITS LEGAL NATURE For use by the holder For use by the Office This request contains the following number of continuation sheets: Office s reference: Holder s reference: INTERNATIONAL REGISTRATION NUMBER(S) (You may use this form for several international registrations of the same holder) NAME OF THE HOLDER (Please type the name of the holder as it is currently recorded in the International Register) CHANGE IN NAME OR ADDRESS OF THE HOLDER (Please indicate the change(s) by ticking the appropriate box(es) and providing the new name or new address) New name: New address: IF THE HOLDER IS A LEGAL ENTITY, RECORDING OF OR CHANGE IN THE INDICATIONS CONCERNING THE LEGAL NATURE OF THE HOLDER (Please provide both the following indications) Legal nature of the legal entity: State (country) and, where applicable, the territorial unit within that State (canton, province, state, etc.), under the laws of which the said legal entity has been organized: MM9(E) July 2017 164
MM9(E) : : : () () (()) ()/() () (): (): MM9(E) July 2017 164
CHANGE IN THE HOLDER S CONTACT INFORMATION (optional) If no change is requested below, the International Bureau will maintain the holder s current contact information, if any Delete the holder s address for correspondence or update it with the information that appears below New address for correspondence: Delete the holder s phone and fax numbers or update them with the information that appears below New telephone: New fax: Delete the holder s e-mail address or update it with the information that appears below New e-mail address: By providing an e-mail address, any further correspondence from the International Bureau related to this/these international registration(s) will be sent only electronically and, therefore, you will no longer receive any paper correspondence. Likewise, any further correspondence from the International Bureau related to other international applications or international registrations for which the same e-mail address has been, or will be, provided will also be sent only electronically. Please note that, for the purpose of electronic communication, there can be only one e-mail address recorded per each international registration. APPOINTMENT OF A (NEW) REPRESENTATIVE (optional) (only complete this item if you are appointing a (new) representative) Name: Address: Telephone: Fax: E-mail address: By providing an e-mail address, any further correspondence from the International Bureau related to this/these international registration(s) will be sent only electronically and, therefore, you will no longer receive any paper correspondence. Likewise, any further correspondence from the International Bureau related to other international applications or international registrations for which the same e-mail address has been, or will be, provided will also be sent only electronically. Please note that, for the purpose of electronic communication, there can be only one e-mail address recorded per each international registration. SIGNATURE OF THE HOLDER APPOINTING THE ABOVE (NEW) REPRESENTATIVE SIGNATURE BY THE HOLDER AND/OR HIS REPRESENTATIVE Holder (as recorded in the International Register) By signing this form, I declare that I am entitled to sign it under the applicable law: Name: Signature: Representative of the holder (as recorded in the International Register or herein appointed) By signing this form, I declare that I am entitled to sign it under the applicable law: Name: Signature: MM9(E) July 2017 165
() : : : : ()() () (): (): : : : () () () (): : (): : MM9(E) July 2017 165
OFFICE OF THE CONTRACTING PARTY OF THE HOLDER PRESENTING THE REQUEST (where this request is presented through an Office) Name of the Office: Name and signature of the official signing on behalf of the Office: By signing this form, I declare that I am entitled to sign it under the applicable law: Name and e-mail address of the contact person in the Office: MM9(E) July 2017 166
() : : : MM9(E) July 2017 166
FEE CALCULATION SHEET (a) INSTRUCTIONS TO DEBIT FROM A CURRENT ACCOUNT The International Bureau is hereby instructed to debit the required amount of fees from a current account opened with the International Bureau (if this box is checked, it is not necessary to complete (b)). Holder of the account: Account number: Identity of the party giving the instructions: (b) AMOUNT OF FEES (The fee is 150 Swiss francs, irrespective of the number of international registrations listed in item 1) Amount (c) METHOD OF PAYMENT Identity of the party effecting the payment: Payment received and acknowledged by WIPO Payment made to WIPO bank account IBAN No. CH51 0483 5048 7080 8100 0 Crédit Suisse, CH-1211 Geneva 70 Swift/BIC: CRESCHZZ80A Payment made to WIPO postal account (within Europe only) IBAN No. CH03 0900 0000 1200 5000 8 Swift/BIC: POFICHBE WIPO receipt number Payment identification Payment identification dd/mm/yyyy dd/mm/yyyy MM9(E) July 2017 167
(a) ( (b)) : : : (b) ( 1 150 ) (c) : WIPO WIPO IBAN No. CH51 0483 5048 7080 8100 0 Crédit Suisse, CH-1211 Geneva 70 Swift/BIC: CRESCHZZ80A WIPO IBAN No. CH03 0900 0000 1200 5000 8 Swift/BIC: POFICHBE WIPO // // MM9(E) July 2017 167
CONTINUATION SHEET No:... of... MM9(E) July 2017 168
No:... of... MM9(E) July 2017 168
REQUEST FOR THE RECORDING OF A CHANGE IN NAME AND/OR ADDRESS OF THE REPRESENTATIVE MM10(E) For use by the representative For use by the Office This request contains the following number of continuation sheets: Office s reference: Representative s reference: INTERNATIONAL REGISTRATION NUMBER(S) (this form may be used for several international registrations of the same representative) NAME OF THE REPRESENTATIVE (as recorded in the International Register) Name: Address: CHANGE IN NAME AND/OR ADDRESS OF THE REPRESENTATIVE (indicate the change(s)) New name: New address: New telephone: New fax: New e-mail address: By providing an e-mail address, any further correspondence from the International Bureau related to this/these international registration(s) will be sent only electronically and, therefore, you will no longer receive any paper correspondence. Likewise, any further correspondence from the International Bureau related to other international applications or international registrations for which the same e-mail address has been, or will be, provided will also be sent only electronically. Please note that, for the purpose of electronic communication, there can be only one e-mail address recorded per each international registration. MM10(E) January 2017 169
MM10(E) : : : () () () (): (): / () (): (): : : : MM10(E) January 2017 169
SIGNATURE BY THE HOLDER AND/OR HIS REPRESENTATIVE Holder Representative of the holder (as recorded in the International Register) (as recorded in the International Register) By signing this form, I declare that I am entitled to sign it under the applicable law: Name: By signing this form, I declare that I am entitled to sign it under the applicable law: Name: Signature: Signature: OFFICE OF THE CONTRACTING PARTY OF THE HOLDER PRESENTING THE REQUEST (where this request is presented through an Office) Name of the Office: Name and signature of the official signing on behalf of the Office: By signing this form, I declare that I am entitled to sign it under the applicable law: Name and e-mail address of the contact person in the Office: MM10(E) January 2017 170
() () (): : (): : () : : : MM10(E) January 2017 170
CONTINUATION SHEET No:... of... MM10(E) January 2017 171
No:... of... MM10(E) January 2017 171
APPOINTMENT OF A REPRESENTATIVE MM12(E) For use by the applicant/holder For use by the Office This request contains the following number of continuation sheets: Office s reference: Applicant/holder s reference: NAME OF THE APPLICANT AND/OR HOLDER (as mentioned in the international application(s) and/or as recorded in the International Register) INTERNATIONAL APPLICATION(S) S REFERENCE(S) AND/OR INTERNATIONAL REGISTRATION NUMBER(S) (this form may be used for several international applications and/or registrations of the same applicant and/or holder) For international applications indicate the basic mark(s), basic application/registration number(s) and date(s) and the filing date of the international application(s) For international registrations indicate the international registrations concerned by the appointment of the representative: REPRESENTATIVE Name: Address: Telephone: Fax: E-mail address: By providing an e-mail address, any further correspondence from the International Bureau related to this/these international application(s) and its/their resulting international registration(s) and/or this/these international registration(s) will be sent only electronically and, therefore, you will no longer receive any paper correspondence. Likewise, any further correspondence from the International Bureau related to other international applications or international registrations for which the same e-mail address has been, or will be, provided will also be sent only electronically. Please note that, for the purpose of electronic communication, there can be only one e-mail address recorded per each international registration. SIGNATURE BY THE APPLICANT AND/OR HOLDER (as indicated in the international application(s) and/or as recorded in the International Register) By signing this form, I declare that I am entitled to sign it under the applicable law: Name: Signature: MM12(E) January 2017 172
MM12(E) / : : : / () (//) / : (): (): : : : () (): : MM12(E) January 2017 172
OFFICE OF THE CONTRACTING PARTY OF THE APPLICANT AND/OR HOLDER PRESENTING THE REQUEST (where this request is presented through an Office) Name of the Office: Name and signature of the official signing on behalf of the Office: By signing this form, I declare that I am entitled to sign it under the applicable law: Name and e-mail address of the contact person in the Office: MM12(E) January 2017 173
() : : : MM12(E) January 2017 173
CONTINUATION SHEET No:... of... MM12(E) January 2017 174
No:... of... MM12(E) January 2017 174
MM13(E) REQUEST FOR THE RECORDING OF A LICENSE For use by the holder For use by the Office This request contains the following number of continuation sheets: Office s reference: Holder s reference: INTERNATIONAL REGISTRATION NUMBER(S) (this form may be used for several international registrations, provided that the licensee is the same and that the license applies to all, or to the same, designated Contracting Parties and concerns all, or the same, goods and services for each of the international registrations) NAME OF THE HOLDER (as recorded in the International Register) LICENSEE (a) Name: (b) Address: (c) Telephone: Fax: E-mail address: By providing an e-mail address, any further correspondence from the International Bureau related to this/these international registration(s) will be sent only electronically and, therefore, you will no longer receive any paper correspondence. Likewise, any further correspondence from the International Bureau related to other international applications or international registrations for which the same e-mail address has been, or will be, provided will also be sent only electronically. Please note that, for the purpose of electronic communication, there can be only one e-mail address recorded per each international registration. MM13(E) January 2017 175
MM13(E) : : : ( ) () () (a) (): (b) (): (c) : : : / MM13(E) January 2017 175
REPRESENTATIVE OF THE LICENSEE Name: Address: Telephone:... Fax: E-mail address: By providing an e-mail address, any further correspondence from the International Bureau related to this/these international registration(s) will be sent only electronically and, therefore, you will no longer receive any paper correspondence. Likewise, any further correspondence from the International Bureau related to other international applications or international registrations for which the same e- mail address has been, or will be, provided will also be sent only electronically. Please note that, for the purpose of electronic communication, there can be only one e-mail address recorded per each international registration. SIGNATURE OF THE LICENSEE APPOINTING THE ABOVE REPRESENTATIVE CONTRACTING PARTIES (a) Contracting Parties with respect to which the license is granted (check one box only): The license is to be recorded for all the Contracting Parties designated in the international registration(s) indicated in item 1; The license is to be recorded for some only of the Contracting Parties designated in the international registration(s) indicated in item 1 (specify those designated Contracting Parties, which must be the same for each international registration): (b) Territorial restriction (if applicable): The license concerns only the part indicated below of the territory of the designated Contracting Party(ies) noted below: If the space provided above is not sufficient, check the box and use a continuation sheet NOTE: Australia, Germany and New Zealand have made the declaration provided for by Rule 20bis(6)(a) of the Common Regulations according to which their laws do not provide for the recording of trademark licenses, so that the recording in the International Register of licenses relating to an international registration of a mark has no effect in those countries. The African Intellectual Property Organization (OAPI), Cambodia, China, Colombia, Georgia, Greece, India, Japan, Kyrgyzstan, Lao People's Democratic Republic, Mexico, Republic of Korea, Republic of Moldova, Russian Federation, Singapore and The Gambia have made the declaration under Rule 20bis(6)(b) of the Common Regulations according to which, while their national legislation provides for the recording of licenses, the recording of licenses in the International Register has no effect in their territory. Consequently, the formalities required for the recording of a license relating to an international registration of a mark in those countries must be completed directly with their national Office, according to the conditions laid down by their respective legislation. MM13(E) January 2017 176
(): (): :... : : / (a) (): ; ( ): (b) (): : : 20 2(6)(a) OAPI 20 2(6)(b) MM13(E) January 2017 176
GOODS AND SERVICES WITH RESPECT TO WHICH THE LICENSE IS GRANTED (check one box only) The license is to be recorded for all the goods and services covered by the international registration(s) indicated in item 1; The license is to be recorded for the goods and services indicated below in respect of the international registration(s) indicated in item 1 (specify those goods and services, which must be grouped in the appropriate classes and be the same for each international registration): You can find indications that are pre-accepted by the International Bureau in the Madrid Goods & Services Manager (MGS) at www.wipo.int/mgs/. Please make consistent use of a semicolon (;) to clearly specify the goods and services indications in your list, e.g.: 09 Scientific, optical and electronic apparatus and instruments; screens for photoengraving; computers. 35 Advertising; compilation of statistics; commercial information agencies. Please use font or Times New Roman, size 12 pt, or above. If the space provided above is not sufficient, check the box and use a continuation sheet MISCELLANEOUS INDICATIONS (optional) (a) Indications concerning the licensee (as may be required by certain designated Contracting Parties): (i) if the licensee is a natural person, nationality of the licensee: (ii) if the licensee is a legal entity: legal nature of the legal entity: State and, where applicable, territorial unit within that State, under the law of which the legal entity is organized: (b) The license is to be recorded as an exclusive license (the license is granted only to one licensee and precludes the holder from using the mark and from granting licenses to any other person); The license is to be recorded as a sole license (the license is granted only to one licensee and precludes the holder from granting licenses to any other person, but does not prevent the holder from using the mark). (c) Duration of the license: SIGNATURE BY THE HOLDER AND/OR HIS REPRESENTATIVE Holder (as recorded in the International Register) By signing this form, I declare that I am entitled to sign it under the applicable law: Name: Signature: Representative of the holder (as recorded in the International Register) By signing this form, I declare that I am entitled to sign it under the applicable law: Name: Signature: MM13(E) January 2017 177
() ; ( ): Madrid Goods & Services Manager (MGS)www.wipo.int/mgs/ ; 09 Scientific, optical and electronic apparatus and instruments; screens for photoengraving; computers. 35 Advertising; compilation of statistics; commercial information agencies. Courier New Times New Roman 12 () (a) (): (i) : (ii) : : : ); ) (b) : / () () (): (): : : MM13(E) January 2017 177
OFFICE OF THE CONTRACTING PARTY OF THE HOLDER PRESENTING THE REQUEST (where applicable) Name of the Office: Name and signature of the official signing on behalf of the Office: By signing this form, I declare that I am entitled to sign it under the applicable law: Name and e-mail address of the contact person in the Office: MM13(E) January 2017 178
() : MM13(E) January 2017 178
FEE CALCULATION SHEET (a) INSTRUCTIONS TO DEBIT FROM A CURRENT ACCOUNT The International Bureau is hereby instructed to debit the required amount of fees from a current account opened with the International Bureau (if this box is checked, it is not necessary to complete (b)). Holder of the account: Account number: Identity of the party giving the instructions: (b) AMOUNT OF FEES Amount (177 Swiss francs) (per international registration mentioned in item 1) Grand total (Swiss francs) (c) METHOD OF PAYMENT Identity of the party effecting the payment: Payment received and acknowledged by WIPO Payment made to WIPO bank account IBAN No. CH51 0483 5048 7080 8100 0 Crédit Suisse, CH-1211 Geneva 70 Swift/BIC: CRESCHZZ80A Payment made to WIPO postal account (within Europe only) IBAN No. CH03 0900 0000 1200 5000 8 Swift/BIC: POFICHBE WIPO receipt number Payment identification Payment identification dd/mm/yyyy dd/mm/yyyy MM13(E) January 2017 179
(a) ( (b)) : : : (b) (177 ) ( ) () (c) : WIPO WIPO WIPO No. CH51 0483 5048 7080 8100 0 Crédit Suisse, CH-1211 Geneva 70 Swift/BIC: CRESCHZZ80A WIPO IBAN No. CH03 0900 0000 1200 5000 8 Swift/BIC: POFICHBE // // MM13(E) January 2017 179
CONTINUATION SHEET No:... of... MM13(E) January 2017 180
No:... of... MM13(E) January 2017 180
MM14(E) REQUEST FOR AMENDMENT OF THE RECORDING OF A LICENSE For use by the holder For use by the Office This request contains the following number of continuation sheets: Office s reference: Holder s reference: INTERNATIONAL REGISTRATION NUMBER(S) (this form may be used for several international registrations of the same holder, provided that the amendment applies to all, or to the same, designated Contracting Parties and concerns all, or the same, goods and services for each of the international registrations concerned) NAME OF THE HOLDER (as recorded in the International Register) LICENSEE (as recorded in the International Register) Name: Address: E-mail address: By providing an e-mail address, any further correspondence from the International Bureau related to this/these international registration(s) will be sent only electronically and, therefore, you will no longer receive any paper correspondence. Likewise, any further correspondence from the International Bureau related to other international applications or international registrations for which the same e-mail address has been, or will be, provided will also be sent only electronically. Please note that, for the purpose of electronic communication, there can be only one e-mail address recorded per each international registration. MM14(E) January 2017 181
MM14(E) : : : ( ) () () () (): (): : MM14(E) January 2017 181
CHANGE(S) (where there are several licenses recorded in respect of the international registrations(s), it should be clearly indicated which license(s) the amendment concerns) Tick the appropriate box(es): (a) (b) New name of the licensee: New address of the licensee: (c) Details of other change(s): SIGNATURE BY THE HOLDER AND/OR HIS REPRESENTATIVE Holder (as recorded in the International Register) By signing this form, I declare that I am entitled to sign it under the applicable law: Name: Signature: Representative of the holder (as recorded in the International Register) By signing this form, I declare that I am entitled to sign it under the applicable law: Name: Signature: OFFICE OF THE CONTRACTING PARTY OF THE HOLDER PRESENTING THE REQUEST (where this request is presented through an Office) Name of the Office: Name and signature of the official signing on behalf of the Office: By signing this form, I declare that I am entitled to sign it under the applicable law: Name and e-mail address of the contact person in the Office: MM14(E) January 2017 182
() : (a) (b) (): (): (c) : / () () (): : (): : () : : : MM14(E) January 2017 182
FEE CALCULATION SHEET (a) INSTRUCTIONS TO DEBIT FROM A CURRENT ACCOUNT The International Bureau is hereby instructed to debit the required amount of fees from a current account opened with the International Bureau (if this box is checked, it is not necessary to complete (b)). Holder of the account: Account number: Identity of the party giving the instructions: (b) AMOUNT OF FEES Amount (177 Swiss francs) (per international registration mentioned in item 1) Grand total (Swiss francs) (c) METHOD OF PAYMENT Identity of the party effecting the payment: Payment received and acknowledged by WIPO Payment made to WIPO bank account IBAN No. CH51 0483 5048 7080 8100 0 Crédit Suisse, CH-1211 Geneva 70 Swift/BIC: CRESCHZZ80A Payment made to WIPO postal account (within Europe only) IBAN No. CH03 0900 0000 1200 5000 8 Swift/BIC: POFICHBE WIPO receipt number Payment identification Payment identification dd/mm/yyyy dd/mm/yyyy MM14(E) January 2017 183
(a) ( (b)) : : : (b) ; (177 ) ( ) () (c) : WIPO WIPO WIPO No. CH51 0483 5048 7080 8100 0 Crédit Suisse, CH-1211 Geneva 70 Swift/BIC: CRESCHZZ80A // WIPO No. CH03 0900 0000 1200 5000 8 Swift/BIC: POFICHBE // MM14(E) January 2017 183
CONTINUATION SHEET No:... of... MM14(E) January 2017 184
No:... of... MM14(E) January 2017 184
MM15(E) REQUEST FOR CANCELLATION OF THE RECORDING OF A LICENSE For use by the holder For use by the Office This request contains the following number of continuation sheets: Office s reference: Holder s reference: INTERNATIONAL REGISTRATION NUMBER(S) (this form may be used for several international registrations of the same holder in respect of which the same license is recorded) NAME OF THE HOLDER (as recorded in the International Register) LICENSEE (as recorded in the International Register) Name: Address: E-mail address: LICENSE(S) TO BE CANCELLED (where there are several licenses recorded in respect of the international registrations(s), it should be clearly indicated which license(s) the cancellation concerns) SIGNATURE BY THE HOLDER AND/OR HIS REPRESENTATIVE Holder (as recorded in the International Register) By signing this form, I declare that I am entitled to sign it under the applicable law: Name: Signature: Representative of the holder (as recorded in the International Register) By signing this form, I declare that I am entitled to sign it under the applicable law: Name: Signature: MM15(E) January 2017 185
MM15(E) : : : () () () () (): (): : () / () () (): : (): : MM15(E) January 2017 185
OFFICE OF THE CONTRACTING PARTY OF THE HOLDER PRESENTING THE REQUEST (where this request is presented through an Office) Name of the Office: Name and signature of the official signing on behalf of the Office: By signing this form, I declare that I am entitled to sign it under the applicable law: Name and e-mail address of the contact person in the Office: MM15(E) January 2017 186
() : : : MM15(E) January 2017 186
CONTINUATION SHEET No:... of... MM15(E) January 2017 187
No:... of... MM15(E) January 2017 187
RESTRICTION OF THE HOLDER S RIGHT OF DISPOSAL MM19(E) For use by the holder For use by the Office Holder s reference: Office s reference: INTERNATIONAL REGISTRATION NUMBER(S) (this form may be used for several international registrations in the name of the same holder, provided that the Contracting Parties in respect of which the international registration is restricted is the same for all of the international registrations concerned) NAME OF THE HOLDER (as recorded in the International Register) MM19(E) January 2017 188
MM19(E) : : ( ) () MM19(E) January 2017 188
CONTRACTING PARTY(IES) CONCERNED (check either (a) or (b)) (a) (b) The restriction of the holder s right of disposal is to be recorded for all the designated Contracting Parties; The restriction of the holder s right of disposal is to be recorded for some only of the designated Contracting Parties. Indicate below, by checking the corresponding box(es), those Contracting Parties: AG Antigua and Barbuda AL Albania AM Armenia AT Austria AU Australia AZ Azerbaijan BA Bosnia and Herzegovina BG Bulgaria BH Bahrain BN Brunei Darussalam BQ Bonaire, Saint Eustatius and Saba 1 BT Bhutan BW Botswana BX Benelux BY Belarus CH Switzerland CN China CO Colombia CU Cuba CW Curaçao 1 CY Cyprus CZ Czechia DE Germany DK Denmark DZ Algeria EE Estonia EG Egypt EM European Union 2 ES Spain FI Finland FR France GB United Kingdom GE Georgia GH Ghana GM Gambia GR Greece HR Croatia HU Hungary IE IL Ireland Israel IN India IR Iran (Islamic Republic of) IS IT Iceland Italy JP Japan KE Kenya KG Kyrgyzstan KH Cambodia KP Democratic People s Republic of Korea KR Republic of Korea KZ Kazakhstan LA Lao People s Democratic Republic LI Liechtenstein LR Liberia LS Lesotho LT Lithuania LV Latvia MA Morocco MC Monaco MD Republic of Moldova ME Montenegro MG Madagascar MK The former Yugoslav Rep. of Macedonia MN Mongolia MX Mexico MZ Mozambique NA Namibia NO Norway NZ New Zealand OA African Intellectual Property Organization (OAPI) 3 OM Oman PH Philippines PL Poland PT Portugal RO Romania RS Serbia RU Russian Federation RW Rwanda SD Sudan SE Sweden SG Singapore SI Slovenia SK Slovakia SL Sierra Leone SM San-Marino ST Sao Tome and Principe SX Sint Maarten (Dutch part) 1 SY Syrian Arab Republic SZ Swaziland TJ Tajikistan TM Turkmenistan TN Tunisia TR Turkey UA Ukraine US United States of America UZ Uzbekistan VN Viet Nam ZM Zambia ZW Zimbabwe Others: 1 Territorial entity previously part of the Netherlands Antilles. 2 The designation of the European Union covers the following Member States: Austria, Belgium, Bulgaria, Croatia, Cyprus, Czechia, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, United Kingdom. 3 The designation of the African Intellectual Property Organization covers the following Member States: Benin, Burkina Faso, Cameroon, Central African Republic, Chad, Comoros, Congo, Côte d Ivoire, Equatorial Guinea, Gabon, Guinea, Guinea-Bissau, Mali, Mauritania, Niger, Senegal, Togo. SUMMARY STATEMENT OF THE MAIN FACTS CONCERNING THE RESTRICTION (only a brief summary of the main facts concerning the restriction is to be given, and no supporting documentation should be attached to the present form. The following example may be used to draft the summary: the holder s right of disposal of the above-mentioned international registration(s) has been restricted in the Contracting Party(ies) indicated in heading 3, following the execution of a., dated., in favour of.. ) MM19(E) January 2017 189
((a) (b)) (a) (b) ; : AG EE LA RS AL EG LI RU AM EM 2 LR RW AT ES LS SD AU FI LT SE AZ FR LV SG BA GB MA SI BG GE MC SK BH GH MD SL BN GM ME SM BQ,, 1 BT BW BX BY CH CN CO CU CW 1 CY CZ DE DK DZ GR HR HU IE IL IN IR IS IT JP KE KG KH KP KR KZ MG MK MN MX MZ NA NO NZ OA (OAPI) 3 OM PH PL PT RO ST SX () 1 SY SZ TJ TM TN TR UA US UZ VN ZM ZW : 1 2 3 (OAPI) ( : 3.,.,.. ) MM19(E) January 2017 189
SIGNATURE BY THE HOLDER AND/OR HIS REPRESENTATIVE Holder (as recorded in the International Register) By signing this form, I declare that I am entitled to sign it under the applicable law: Name: Signature: Representative of the holder (as recorded in the International Register) By signing this form, I declare that I am entitled to sign it under the applicable law: Name: Signature: OFFICE OF THE CONTRACTING PARTY PRESENTING THE REQUEST (where this request is presented through an Office) Name of the Office: Name and signature of the official signing on behalf of the Office: By signing this form, I declare that I am entitled to sign it under the applicable law: Name and e-mail address of the contact person in the Office: MM19(E) January 2017 190
() () () : : : : () : : : MM19(E) January 2017 190
MM20(E) REQUEST FOR CONTINUED PROCESSING For use by the applicant or holder This request for continued processing contains the following number of continuation sheets: Applicant s or holder s reference: WIPO REFERENCE NUMBER (Please, provide the 9 or 10-digit number that appears in the notice of irregularity or in the notification sent under Rules 34 or 39 as part of the WIPO reference number. Type one digit in each box. For example, for reference number EN-I/783955701/LB, type: 783955701) PLEASE, PROVIDE ONE OF THE FOLLOWING (Where the request relates to more than one international registration, just provide the number of one of those registrations; where the request concerns an international application, please provide either the basic application number or the basic registration number) (a) International registration number: (b) Basic application number: (c) Basic registration number: APPLICANT OF THE INTERNATIONAL APPLICATION (AS PROVIDED IN THE INTERNATIONAL APPLICATION) OR HOLDER OF THE INTERNATIONAL REGISTRATION (AS RECORDED IN THE INTERNATIONAL REGISTER) Name: REQUEST FOR CONTINUED PROCESSING (Check the box that applies) The payment of fees in connection with an irregularity under Rules 11(2) and (3), 20bis(2), 24(5)(b) or 26(2). An irregularity relating to an international application or international registration under Rules 11(2) and (3), 20bis(2), 24(5)(b) or 26(2), but not to the payment of fees. The payment of the second part of an individual fee under Rule 34(3)(c)(iii). A request that an international registration continues its effects in a successor State and payment of the fees related to this request under Rule 39(1). SIGNATURE BY THE APPLICANT, HOLDER AND/OR HIS REPRESENTATIVE Applicant or holder (as provided in the international application or recorded in the International Register) By signing this form, I declare that I am entitled to sign it under the applicable law: Name: Signature: Representative of the applicant or holder (as provided in the international application or recorded in the International Register) By signing this form, I declare that I am entitled to sign it under the applicable law: Name: Signature: MM20(E) February 2017 191
MM20(E) : : WIPO ( 34 39 WIPO 9 10 EEN-I/783955701/LB 783955701 ) ( ) (a) : (b) : (c) : (): () 11 (2) (3) 20 2(2) 24 (5)(b) 26 (2) 11 (2) (3) 20 2(2) 24 (5)(b) 26 (2) 34 (3)(c)(iii) 39 (1) ( ) ( ) (): : (): : MM20(E) February 2017 191
FEE CALCULATION SHEET (a) INSTRUCTIONS TO DEBIT FROM A CURRENT ACCOUNT The International Bureau is hereby instructed to debit the required amount of fees from a current account opened with the International Bureau (if this box is checked, it is not necessary to complete (b)). Holder of the account: Account number: Identity of the party giving the instructions: (b) AMOUNT OF FEES (The fee for continued processing is 200 Swiss francs, irrespective of the number of international registrations listed in item 1) TOTAL (Swiss francs) 200.-- (c) METHOD OF PAYMENT Identity of the party effecting the payment: Payment received and acknowledged by WIPO Payment made to WIPO bank account IBAN No. CH51 0483 5048 7080 8100 0 Crédit Suisse, CH-1211 Geneva 70 Swift/BIC: CRESCHZZ80A Payment made to WIPO postal account (within Europe only) IBAN No. CH03 0900 0000 1200 5000 8 Swift/BIC: POFICHBE WIPO receipt number Payment identification Payment identification dd/mm/yyyy dd/mm/yyyy MM20(E) February 2017 192
(a) ( (b)) : : : (b) ( 1 200 ) () 200.-- (c) : WIPO WIPO No. CH51 0483 5048 7080 8100 0 Crédit Suisse, CH-1211 Geneva 70 Swift/BIC: CRESCHZZ80A WIPO No. CH03 0900 0000 1200 5000 8 Swift/BIC: POFICHBE WIPO // // MM20(E) February 2017 192
CONTINUATION SHEET No :... of... MM20(E) February 2017 193
No :... of... MM20(E) February 2017 193
MM21(E) REQUEST FOR THE CORRECTION OF A RECORDING For use by the holder This form includes the following number of continuation sheets: For use by the Office This form includes the following number of continuation sheets: Holder s reference: Office s reference: INTERNATIONAL REGISTRATION NUMBER (Please, provide the international registration number (and the letter, if any). Type one digit in each box. For example, for international registration number 123456A, type 123456A) REFERENCE NUMBER (a) If the holder or his/her representative requests the correction: WIPO REFERENCE NUMBER (Please, provide the 9 or 10-digit number that appears in the notification as part of the WIPO reference number. Type one digit in each box. For example, for reference number 806/123456789, type: 123456789) (b) If the Office requests the correction: WIPO NOTIFICATION NUMBER (Please, provide the 3-letter and the 6-digit number that appear in the notification. Type one letter or digit in each box. For example, for reference number ENN/2014/01, type: ENN201401) MM21(E) February 2017 194
MM21(E) : : : : (() 123456A 123456A ) (a) : WIPO ( WIPO 9 10 806/123456789 123456789 ) (b) : WIPO ( 3 6 ENN/2014/01 ENN201401 ) MM21(E) February 2017 194
DESCRIPTION OF THE REQUESTED CORRECTION (Please, provide details of the error to be corrected) If the space provided above is not sufficient, check the box and use a continuation sheet. PRESENTATION AND SIGNATURE (a) The request is presented by (please, check the appropriate box): (i) Holder (ii) Representative of the holder (iii) Office By signing this form, I declare that I am entitled to sign it under the applicable law: (b) (c) (d) Name: Signature: E-mail address: MM21(E) February 2017 195
() (a) (): (i) (ii) (iii) (b) (c) (d) : : : MM21(E) February 2017 195
CONTINUATION SHEET No:... of... MM21(E) February 2017 196
No:... of... MM21(E) February 2017 196
MM16(E) SUBSEQUENT DESIGNATION RESULTING FROM CONVERSION For use by the holder This subsequent designation contains the following number of continuation sheets: Office s reference: For use by the Office Holder s reference: INTERNATIONAL REGISTRATION NUMBER HOLDER (as recorded in the International Register) Name: Address: E-mail address: By providing an e-mail address, any further correspondence from the International Bureau related to this international registration will be sent only electronically and, therefore, you will no longer receive any paper correspondence. Likewise, any further correspondence from the International Bureau related to other international applications or international registrations for which the same e-mail address has been, or will be, provided will also be sent only electronically. Please note that, for the purpose of electronic communication, there can be only one e-mail address recorded per each international registration. APPOINTMENT OF A (NEW) REPRESENTATIVE (only complete this item if you are appointing a (new) representative) Name: Address: Telephone: E-mail address: Fax: By providing an e-mail address, any further correspondence from the International Bureau related to this international registration will be sent only electronically and, therefore, you will no longer receive any paper correspondence. Likewise, any further correspondence from the International Bureau related to other international applications or international registrations for which the same e-mail address has been, or will be, provided will also be sent only electronically. Please note that, for the purpose of electronic communication, there can be only one e-mail address recorded per each international registration. SIGNATURE OF THE HOLDER APPOINTING THE ABOVE (NEW) REPRESENTATIVE MM16(E) January 2017 197