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 PHILIPPINE INTELLECTUAL PROPERTY BRIEF
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APPLICATION FORM FOR REGISTRATION OF
INDUSTRIAL DESIGNS
 
 
THE UNDERSIGNED HEREBY REQUESTS THAT THIS INDUSTRIAL DESIGN APPLICATION BE REGISTERED. (The following is to be filled in by the Intellectual Property Office)    
APPLICATION NO.:     
 
FILING DATE:   
 
DATE OF RECEIPT:    
 
Box No. I   TITLE OF THE DESIGN: 

 
Box No. II APPLICANT (WHETHER OR NOT ALSO DESIGNER): Use this box for indicating the applicant or, if  there are several applicants, one of them. If more than one person (include, where applicable, a legal entity) is involved, continue in the supplemental box.        

The person in this box is (check one only):  o  Applicant and Designer     o  Applicant Only     

Name and address:        
    
     

Telephone Number:               Fax Number:                E-Mail address:      
[including area code]      

Country of Nationality:                                    Country of Residence:      

 

Box No. III   DESIGNER/S:   A separate sub-box has to be filled in  in respect of each person. If the following two sub-boxes are  insufficient, continue in the "Supplemental Box" (giving therein for each additional person the same indications as those requested in the following two sub-boxes) or by using a "continuation sheet".      

The person in this box is (check one only):  o Applicant and Designer         o Designer Only     

Name and address:     
      
     

If the person identified in this sub-box is applicant (or applicant and designer), indicate also:     

Country of Nationality:                                    Country of Residence:     

 

The person identified in this box is (check one only):  o Applicant and Designer   o Designer Only     

Name and address:      
      
     

If the person identified in this sub-box is applicant (or applicant and designer), indicate also:      

Country of Nationality:                                    Country of Residence:     

 
 
 
 
 Sheet Number 2
Box No. IV  AGENT (IF ANY) OR COMMON REPRESENTATIVE (IF ANY): ADDRESS FOR NOTIFICATION (IN CERTAIN CASES) A common representative may be appointed only if there are several applicants and if no agent is/or has been appointed: The common representative must be one of the applicants. The following person (include, where applicable, a legal entity) is hereby/has been appointed as agent or  common representative to act on behalf of the applicant(s) before the Intellectual Property Office.   

Name and address, including postal code:    
     
     
     

Telephone Number:                       Fax No.:                   E-Mail address:   
(including area code)   
 
Box No. V  PRIORITY CLAIM (IF ANY):  The priority of the following earlier application(s) is hereby claimed:       

Country in which it was filed:           Filing Date              Application No.    
                                                      (month, day, year)       

(1)________________________________________________________________________________________      

(2)________________________________________________________________________________________     

(3)________________________________________________________________________________________     
 
Box No. VI  SIGNATURE OF APPLICANT(S) OR AGENT OVER PRINTED NAME(S):   
  
    
    
   
   
     
    
  

If the present Request form is signed on behalf of any applicant by an agent, a separate notarized power of  attorney appointing the agent and signed by the applicant is required. If in such case it is desired to make use of a general power of attorney (deposited with the Intellectual Property Office), a copy thereof must be attached to this form. 
Box No. VII  CHECK LIST (To be filled in by the Applicant)
This application contains the following number of 
sheets:  
1. Request:    
2. Description : 
3. Claim(s): 
4. Drawing(s): 
Total Sheets: 

Figure number(s) __________ of the drawings (if any)  
is suggested to accompany the abstract for publication. 

 This application as filed is accompanied by the items checked below.   

   o Separate notarized power of attorney  
   o Copy of general power of attorney  
   o Priority document(s) (see Box No. V)  
   o Cheques for the payment of fees   
   o Other documents (specify)  
 
 
   
Sheet Number 3
Supplemental Box:    Use this box in the following cases:      

i.     if more than three persons are involved as applicants and/or designers: in such case, write  
       "Continuation of Box No. III" and indicate for each additional person the same type of 
       information as required in Box No. III; 
ii.     if there are more than three earlier applications whose priority is claimed: in such case, 
       indicate "Continuation of Box  No. V" and indicate for each additional earlier application the 
       same type of information as required in Box No. V; and    
iii.    if, in any of the Boxes, the space is insufficient to furnish the information: in such case, 
       write "Continuation of Box No." (indicate the number of the box) and furnish the information 
       in the same manner as required  according to the captions of the Box in which the space was 
       insufficient.      
 

  
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
            
   
   
 
If this supplemental Box is not used, this sheet need not be included in the Request.
 
 IPO-BP Form 3C
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