THE UNDERSIGNED
HEREBY REQUEST THAT THIS
UTILITY MODEL APPLICATION BE REGISTERED. |
(The following is to be filled
in by the Intellectual Property Office)
APPLICATION NO.: |
FILING DATE:
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DATE OF RECEIPT:
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Box No. I TITLE
OF THE UTILITY MODEL:
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Box No. II APPLICANT:
(WHETHER
OR NOT ALSO MAKER) 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 Maker o Applicant Only Name and Address:
Telephone Number:
Fax Number:
E-Mail address:
Country of Nationality: Country of Residence:
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Box No. III MAKER/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 Maker o Maker Only Name and Address:
If the person identified in this sub-box is applicant (or applicant and maker ), indicate also: Country of Nationality: Country of Residence:
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The person
identified in this box is (check one only): o Applicant
and Maker o Maker Only
Name and Address:
If the person identified in this sub-box is applicant (or applicant and maker ), indicate also: Country of Nationality: Country of Residence:
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Box No. IV AGENT (IF ANY)
OR COMMON REPRESENTATIVE (IF ANY):
ADDRESS FOR NOTIFICATIONS (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:
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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.
(1)__________________________________________________________________________ (2)__________________________________________________________________________ (3)__________________________________________________________________________
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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. |
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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
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Supplemental Box:
Use this box in the following cases:
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