MM4
来源机关：国家知识产权局商标局
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MM4 (E) – DESIGNATION SUBSEQUENT TO THE INTERNATIONAL REGISTRATION
We strongly recommend that you use eMadrid to request a subsequent designation.
| For use by the holder: | For use by the holder: |
| Number of continuation sheets: | |
| Number of MM17 forms: | |
| MM18 form (if applicable, check the box) | MM18 form (if applicable, check the box) |
| Holder’s reference: | |
| For use by the Office of origin: | For use by the Office of origin: |
| Office’s reference: |
| 1. INTERNATIONAL REGISTRATION NUMBER |
| 2. NAME OF THE HOLDER As recorded in the International Register. |
| 3. E-MAIL ADDRESS OF THE HOLDER AND THE REPRESENTATIVE You must indicate the e-mail address of the holder and representative (if applicable) only if these addresses have not already been provided for the international registration indicated in item 1 of this form. If an e-mail address has already been provided, any e-mail address indicated below will be disregarded. | 3. E-MAIL ADDRESS OF THE HOLDER AND THE REPRESENTATIVE You must indicate the e-mail address of the holder and representative (if applicable) only if these addresses have not already been provided for the international registration indicated in item 1 of this form. If an e-mail address has already been provided, any e-mail address indicated below will be disregarded. | 3. E-MAIL ADDRESS OF THE HOLDER AND THE REPRESENTATIVE You must indicate the e-mail address of the holder and representative (if applicable) only if these addresses have not already been provided for the international registration indicated in item 1 of this form. If an e-mail address has already been provided, any e-mail address indicated below will be disregarded. |
| (a) | E-mail address of the holder: | |
| (b) | E-mail address of the representative: | |
| 4. DESIGNATIONS | 4. DESIGNATIONS | 4. DESIGNATIONS | 4. DESIGNATIONS |
| Check the corresponding boxes: | Check the corresponding boxes: | Check the corresponding boxes: | Check the corresponding boxes: |
| AE United Arab Emirates AF Afghanistan AG Antigua and Barbuda AL Albania AM Armenia AT Austria AU Australia AZ Azerbaijan BA Bosnia and Herzegovina BG Bulgaria BH Bahrain BN Brunei Darussalamb BQ Bonaire, Sint Eustatius and Sabaf,g BR Brazilh,i BT Bhutan BW Botswana BX Beneluxj BZ Belizeb BY Belarus CA Canada CH Switzerland CL Chile CN China CO Colombia CU Cubae CV Cabo Verdeb CW Curaçaof CY Cyprus CZ Czech Republic DE Germany DK Denmark | DZ Algeria EE Estoniah EG Egypt EM European Uniona ES Spain FI Finland FR France GB United Kingdomb,k GD Grenada GE Georgia GG Guernseyb,l GH Ghana GM Gambia GR Greece HR Croatia HU Hungary ID Indonesia IE Irelandb IL Israel IN Indiab,h IR Iran (Islamic Republic of) IS Iceland IT Italy JM Jamaica 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 Lesothob LT Lithuania LV Latvia MA Morocco MC Monaco MD Republic of Moldova ME Montenegro MG Madagascar MK North Macedonia MN Mongolia MU Mauritius MW Malawib MX Mexico MY Malaysiab MZ Mozambiqueb NA Namibia NO Norway NZ New Zealandb OA African Intellectual Property Organization (OAPI)c OM Oman PH Philippinesh PK Pakistanb PL Poland PT Portugal QA Qatar | RO Romania RS Serbia RU Russian Federation RW Rwanda SD Sudan SE Sweden SG Singaporeb SI Slovenia SK Slovakia SL Sierra Leone SM San Marino ST Sao Tome and Principe SX Sint Maarten (Dutch part)f SY Syrian Arab Republic SZ Eswatini TH Thailand TJ Tajikistan TM Turkmenistan TN Tunisia TR Türkiye TT Trinidad and Tobagob UA Ukraine US United States of Americad UZ Uzbekistan VN Viet Nam WS Samoa ZM Zambia ZW Zimbabwe |
| a The designation of the European Union covers its Member States (Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands (Kingdom of the), Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden). If the European Union is designated, it is compulsory to indicate a second language before the Office of the European Union. The second language must be chosen from among the following five languages but may not be the language of the international application from which the international registration indicated in item 1 resulted, regardless of the language of the present subsequent designation. Thus, for example, if the international application was filed in French and this subsequent designation is in English, French may not be selected as the second language (check one box only). English French German Italian Spanish Moreover, if the applicant wishes to claim the seniority of an earlier mark registered in, or for, a Member State of the European Union, the official form MM17 must be annexed to the present subsequent designation. b By designating Belize, Brunei Darussalam, Cabo Verde, Guernsey, India, Ireland, Lesotho, Malawi, Malaysia, Mozambique, New Zealand, Pakistan, Singapore, Trinidad and Tobago or the United Kingdom, the holder declares that he/she has the intention that the mark will be used by him/her or with his/her consent in that country/territory in connection with the goods and services identified in the present subsequent designation. c The designation of the African Intellectual Property Organization (OAPI) 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. d If the United States of America is designated, it is compulsory to annex to the present international application the official form MM18 containing the declaration of intention to use the mark required by this Contracting Party. Item 6(a) of the present form should also be completed. e Cuba has made a notification under Rule 34(3)(a) of the Common Regulations (individual fees payable in two parts). Therefore, if Cuba is designated, only the first part of the applicable individual fee is payable at the time of filing the present subsequent designation. The second part will have to be paid only if the Office is satisfied that the mark which is the subject of the international registration qualifies for protection. The date by which the second part must be paid, and the amount due, will be notified to the holder of the international registration at a later stage. f Territorial entity previously part of the former Netherlands Antilles. g Protection in BQ (Bonaire, Sint Eustatius and Saba) is granted automatically with the designation (see Information Notice No. 27/2011). h Brazil, Estonia, India and the Philippines have made the declaration referred to in Article 14(5) of the Protocol. Accordingly, it is not possible to subsequently designate Brazil in respect of international registrations effected prior to October 2, 2019, Estonia in respect of international registrations effected prior to November 18, 1998, India in respect of international registrations effected prior to July 8, 2013, and the Philippines in respect of international registrations effected prior to July 25, 2012. i By designating Brazil, the holder declares that the holder, or a company controlled by the holder, effectively and lawfully conducts business in connection with the goods and services for which Brazil is being designated; and, agrees to receive notifications, including summons, not covered by the Madrid Protocol concerning the international registration of the mark that is the subject of this subsequent designation, issued in judicial proceedings held in Brazil, by post. j The designation of Benelux covers the following States: Belgium, Luxembourg and Netherlands (Kingdom of the). k The designation of the United Kingdom covers England, Wales, Scotland, Northern Ireland, the British Overseas Territory of the Falkland Islands (Malvinas) and Gibraltar, as well as the two British Crown Dependencies of the Isle of Man and Jersey (see Information Notices No. 38/2015 and 77/2020). l The Bailiwick of Guernsey is a self-governing British Crown Dependency (see Information Notice No. 77/2020). | a The designation of the European Union covers its Member States (Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands (Kingdom of the), Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden). If the European Union is designated, it is compulsory to indicate a second language before the Office of the European Union. The second language must be chosen from among the following five languages but may not be the language of the international application from which the international registration indicated in item 1 resulted, regardless of the language of the present subsequent designation. Thus, for example, if the international application was filed in French and this subsequent designation is in English, French may not be selected as the second language (check one box only). English French German Italian Spanish Moreover, if the applicant wishes to claim the seniority of an earlier mark registered in, or for, a Member State of the European Union, the official form MM17 must be annexed to the present subsequent designation. b By designating Belize, Brunei Darussalam, Cabo Verde, Guernsey, India, Ireland, Lesotho, Malawi, Malaysia, Mozambique, New Zealand, Pakistan, Singapore, Trinidad and Tobago or the United Kingdom, the holder declares that he/she has the intention that the mark will be used by him/her or with his/her consent in that country/territory in connection with the goods and services identified in the present subsequent designation. c The designation of the African Intellectual Property Organization (OAPI) 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. d If the United States of America is designated, it is compulsory to annex to the present international application the official form MM18 containing the declaration of intention to use the mark required by this Contracting Party. Item 6(a) of the present form should also be completed. e Cuba has made a notification under Rule 34(3)(a) of the Common Regulations (individual fees payable in two parts). Therefore, if Cuba is designated, only the first part of the applicable individual fee is payable at the time of filing the present subsequent designation. The second part will have to be paid only if the Office is satisfied that the mark which is the subject of the international registration qualifies for protection. The date by which the second part must be paid, and the amount due, will be notified to the holder of the international registration at a later stage. f Territorial entity previously part of the former Netherlands Antilles. g Protection in BQ (Bonaire, Sint Eustatius and Saba) is granted automatically with the designation (see Information Notice No. 27/2011). h Brazil, Estonia, India and the Philippines have made the declaration referred to in Article 14(5) of the Protocol. Accordingly, it is not possible to subsequently designate Brazil in respect of international registrations effected prior to October 2, 2019, Estonia in respect of international registrations effected prior to November 18, 1998, India in respect of international registrations effected prior to July 8, 2013, and the Philippines in respect of international registrations effected prior to July 25, 2012. i By designating Brazil, the holder declares that the holder, or a company controlled by the holder, effectively and lawfully conducts business in connection with the goods and services for which Brazil is being designated; and, agrees to receive notifications, including summons, not covered by the Madrid Protocol concerning the international registration of the mark that is the subject of this subsequent designation, issued in judicial proceedings held in Brazil, by post. j The designation of Benelux covers the following States: Belgium, Luxembourg and Netherlands (Kingdom of the). k The designation of the United Kingdom covers England, Wales, Scotland, Northern Ireland, the British Overseas Territory of the Falkland Islands (Malvinas) and Gibraltar, as well as the two British Crown Dependencies of the Isle of Man and Jersey (see Information Notices No. 38/2015 and 77/2020). l The Bailiwick of Guernsey is a self-governing British Crown Dependency (see Information Notice No. 77/2020). | a The designation of the European Union covers its Member States (Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands (Kingdom of the), Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden). If the European Union is designated, it is compulsory to indicate a second language before the Office of the European Union. The second language must be chosen from among the following five languages but may not be the language of the international application from which the international registration indicated in item 1 resulted, regardless of the language of the present subsequent designation. Thus, for example, if the international application was filed in French and this subsequent designation is in English, French may not be selected as the second language (check one box only). English French German Italian Spanish Moreover, if the applicant wishes to claim the seniority of an earlier mark registered in, or for, a Member State of the European Union, the official form MM17 must be annexed to the present subsequent designation. b By designating Belize, Brunei Darussalam, Cabo Verde, Guernsey, India, Ireland, Lesotho, Malawi, Malaysia, Mozambique, New Zealand, Pakistan, Singapore, Trinidad and Tobago or the United Kingdom, the holder declares that he/she has the intention that the mark will be used by him/her or with his/her consent in that country/territory in connection with the goods and services identified in the present subsequent designation. c The designation of the African Intellectual Property Organization (OAPI) 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. d If the United States of America is designated, it is compulsory to annex to the present international application the official form MM18 containing the declaration of intention to use the mark required by this Contracting Party. Item 6(a) of the present form should also be completed. e Cuba has made a notification under Rule 34(3)(a) of the Common Regulations (individual fees payable in two parts). Therefore, if Cuba is designated, only the first part of the applicable individual fee is payable at the time of filing the present subsequent designation. The second part will have to be paid only if the Office is satisfied that the mark which is the subject of the international registration qualifies for protection. The date by which the second part must be paid, and the amount due, will be notified to the holder of the international registration at a later stage. f Territorial entity previously part of the former Netherlands Antilles. g Protection in BQ (Bonaire, Sint Eustatius and Saba) is granted automatically with the designation (see Information Notice No. 27/2011). h Brazil, Estonia, India and the Philippines have made the declaration referred to in Article 14(5) of the Protocol. Accordingly, it is not possible to subsequently designate Brazil in respect of international registrations effected prior to October 2, 2019, Estonia in respect of international registrations effected prior to November 18, 1998, India in respect of international registrations effected prior to July 8, 2013, and the Philippines in respect of international registrations effected prior to July 25, 2012. i By designating Brazil, the holder declares that the holder, or a company controlled by the holder, effectively and lawfully conducts business in connection with the goods and services for which Brazil is being designated; and, agrees to receive notifications, including summons, not covered by the Madrid Protocol concerning the international registration of the mark that is the subject of this subsequent designation, issued in judicial proceedings held in Brazil, by post. j The designation of Benelux covers the following States: Belgium, Luxembourg and Netherlands (Kingdom of the). k The designation of the United Kingdom covers England, Wales, Scotland, Northern Ireland, the British Overseas Territory of the Falkland Islands (Malvinas) and Gibraltar, as well as the two British Crown Dependencies of the Isle of Man and Jersey (see Information Notices No. 38/2015 and 77/2020). l The Bailiwick of Guernsey is a self-governing British Crown Dependency (see Information Notice No. 77/2020). | a The designation of the European Union covers its Member States (Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands (Kingdom of the), Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden). If the European Union is designated, it is compulsory to indicate a second language before the Office of the European Union. The second language must be chosen from among the following five languages but may not be the language of the international application from which the international registration indicated in item 1 resulted, regardless of the language of the present subsequent designation. Thus, for example, if the international application was filed in French and this subsequent designation is in English, French may not be selected as the second language (check one box only). English French German Italian Spanish Moreover, if the applicant wishes to claim the seniority of an earlier mark registered in, or for, a Member State of the European Union, the official form MM17 must be annexed to the present subsequent designation. b By designating Belize, Brunei Darussalam, Cabo Verde, Guernsey, India, Ireland, Lesotho, Malawi, Malaysia, Mozambique, New Zealand, Pakistan, Singapore, Trinidad and Tobago or the United Kingdom, the holder declares that he/she has the intention that the mark will be used by him/her or with his/her consent in that country/territory in connection with the goods and services identified in the present subsequent designation. c The designation of the African Intellectual Property Organization (OAPI) 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. d If the United States of America is designated, it is compulsory to annex to the present international application the official form MM18 containing the declaration of intention to use the mark required by this Contracting Party. Item 6(a) of the present form should also be completed. e Cuba has made a notification under Rule 34(3)(a) of the Common Regulations (individual fees payable in two parts). Therefore, if Cuba is designated, only the first part of the applicable individual fee is payable at the time of filing the present subsequent designation. The second part will have to be paid only if the Office is satisfied that the mark which is the subject of the international registration qualifies for protection. The date by which the second part must be paid, and the amount due, will be notified to the holder of the international registration at a later stage. f Territorial entity previously part of the former Netherlands Antilles. g Protection in BQ (Bonaire, Sint Eustatius and Saba) is granted automatically with the designation (see Information Notice No. 27/2011). h Brazil, Estonia, India and the Philippines have made the declaration referred to in Article 14(5) of the Protocol. Accordingly, it is not possible to subsequently designate Brazil in respect of international registrations effected prior to October 2, 2019, Estonia in respect of international registrations effected prior to November 18, 1998, India in respect of international registrations effected prior to July 8, 2013, and the Philippines in respect of international registrations effected prior to July 25, 2012. i By designating Brazil, the holder declares that the holder, or a company controlled by the holder, effectively and lawfully conducts business in connection with the goods and services for which Brazil is being designated; and, agrees to receive notifications, including summons, not covered by the Madrid Protocol concerning the international registration of the mark that is the subject of this subsequent designation, issued in judicial proceedings held in Brazil, by post. j The designation of Benelux covers the following States: Belgium, Luxembourg and Netherlands (Kingdom of the). k The designation of the United Kingdom covers England, Wales, Scotland, Northern Ireland, the British Overseas Territory of the Falkland Islands (Malvinas) and Gibraltar, as well as the two British Crown Dependencies of the Isle of Man and Jersey (see Information Notices No. 38/2015 and 77/2020). l The Bailiwick of Guernsey is a self-governing British Crown Dependency (see Information Notice No. 77/2020). |
| 5. GOODS AND SERVICES CONCERNED BY THE SUBSEQUENT DESIGNATION Check only one box. | 5. GOODS AND SERVICES CONCERNED BY THE SUBSEQUENT DESIGNATION Check only one box. | 5. GOODS AND SERVICES CONCERNED BY THE SUBSEQUENT DESIGNATION Check only one box. |
| (a) | The subsequent designation is made, in respect of all the Contracting Parties designated in item 4, for all the goods and services listed in the international registration indicated in item 1. | |
| (b) | The subsequent designation is made, in respect of all the Contracting Parties designated in item 4, only for those goods and services listed in the continuation sheet (which must be grouped in the appropriate class(es)). | |
| (c) | The subsequent designation is only for those goods and services listed in the continuation sheet in respect of the Contracting Parties identified in the said continuation sheet; in respect of the other Contracting Parties designated in item 4, the subsequent designation is for all the goods and services listed in the international registration identified in item 1. |
| 6. MISCELLANEOUS INDICATIONS Only provide these indications or translations if they are not already recorded in the International Register; if this is the case, the International Bureau will disregard any new indication or translation provided in this item. | 6. MISCELLANEOUS INDICATIONS Only provide these indications or translations if they are not already recorded in the International Register; if this is the case, the International Bureau will disregard any new indication or translation provided in this item. | 6. MISCELLANEOUS INDICATIONS Only provide these indications or translations if they are not already recorded in the International Register; if this is the case, the International Bureau will disregard any new indication or translation provided in this item. | 6. MISCELLANEOUS INDICATIONS Only provide these indications or translations if they are not already recorded in the International Register; if this is the case, the International Bureau will disregard any new indication or translation provided in this item. | 6. MISCELLANEOUS INDICATIONS Only provide these indications or translations if they are not already recorded in the International Register; if this is the case, the International Bureau will disregard any new indication or translation provided in this item. | 6. MISCELLANEOUS INDICATIONS Only provide these indications or translations if they are not already recorded in the International Register; if this is the case, the International Bureau will disregard any new indication or translation provided in this item. |
| (a) | Indications concerning the holder (as may be required by certain designated Contracting Parties, such as, for example, the United States of America; only provide indications in either item (i) or in item (ii) but not in both items): | Indications concerning the holder (as may be required by certain designated Contracting Parties, such as, for example, the United States of America; only provide indications in either item (i) or in item (ii) but not in both items): | Indications concerning the holder (as may be required by certain designated Contracting Parties, such as, for example, the United States of America; only provide indications in either item (i) or in item (ii) but not in both items): | Indications concerning the holder (as may be required by certain designated Contracting Parties, such as, for example, the United States of America; only provide indications in either item (i) or in item (ii) but not in both items): | Indications concerning the holder (as may be required by certain designated Contracting Parties, such as, for example, the United States of America; only provide indications in either item (i) or in item (ii) but not in both items): |
| (i) | If the holder is a natural person, nationality of the holder: | If the holder is a natural person, nationality of the holder: | If the holder is a natural person, nationality of the holder: | ||
| Nationality of the holder: | |||||
| (ii) | If the holder is a legal entity, provide both of the following indications: | If the holder is a legal entity, provide both of the following indications: | If the holder is a legal entity, provide both of the following indications: | ||
| Legal nature of the legal entity: | Legal nature of the legal entity: | ||||
| State (country) and, where applicable, territorial unit within that State (canton, province, state, etc.), under the law of which the said legal entity has been organized: | State (country) and, where applicable, territorial unit within that State (canton, province, state, etc.), under the law of which the said legal entity has been organized: | ||||
| (b) | Indication, for each color, of the principal parts of the mark that are in that color (as may be required by certain designated Contracting Parties): | Indication, for each color, of the principal parts of the mark that are in that color (as may be required by certain designated Contracting Parties): | Indication, for each color, of the principal parts of the mark that are in that color (as may be required by certain designated Contracting Parties): |
| (c) | Translation of the mark (as may be required by certain designated Contracting Parties; do not check the box in item (d) if you provide a translation in this item): | Translation of the mark (as may be required by certain designated Contracting Parties; do not check the box in item (d) if you provide a translation in this item): | Translation of the mark (as may be required by certain designated Contracting Parties; do not check the box in item (d) if you provide a translation in this item): |
| (i) | Into English: | ||
| (ii) | Into French: | ||
| (iii) | Into Spanish: | ||
| (d) | Check this box if the words contained in the mark have no meaning (and therefore cannot be translated; do not check this box if you have provided a translation in item (c)). | Check this box if the words contained in the mark have no meaning (and therefore cannot be translated; do not check this box if you have provided a translation in item (c)). | |
| (e) | Voluntary description of the mark (any description of the mark by words, including the description contained in the basic application or basic registration, if you were not required to provide this description in item 9(e)(i) of the international application form MM2): | Voluntary description of the mark (any description of the mark by words, including the description contained in the basic application or basic registration, if you were not required to provide this description in item 9(e)(i) of the international application form MM2): | Voluntary description of the mark (any description of the mark by words, including the description contained in the basic application or basic registration, if you were not required to provide this description in item 9(e)(i) of the international application form MM2): |
| 7. DATE OF THE SUBSEQUENT DESIGNATION Check only one box. | 7. DATE OF THE SUBSEQUENT DESIGNATION Check only one box. | 7. DATE OF THE SUBSEQUENT DESIGNATION Check only one box. |
| (a) | This subsequent designation shall take effect after the renewal of the international registration indicated in item 1. | |
| (b) | This subsequent designation shall take effect after the recording in the International Register of the following change or cancellation in respect of the international registration indicated in item 1 (specify the change or cancellation): | |
| 8. SIGNATURE OF THE HOLDER AND/OR THEIR REPRESENTATIVE | 8. SIGNATURE OF THE HOLDER AND/OR THEIR REPRESENTATIVE |
| Holder (as recorded in the International Register): | Holder (as recorded in the International Register): |
| 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: | |
| Signature: | |
| Representative of the holder (as recorded in the International Register): | 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: | By signing this form, I declare that I am entitled to sign it under the applicable law: |
| Name: | |
| Signature: |
| 9. DATE OF RECEIPT AND DECLARATION BY THE OFFICE OF THE CONTRACTING PARTY OF THE HOLDER PRESENTING THE SUBSEQUENT DESIGNATION Where the subsequent designation is presented through an Office. | 9. DATE OF RECEIPT AND DECLARATION BY THE OFFICE OF THE CONTRACTING PARTY OF THE HOLDER PRESENTING THE SUBSEQUENT DESIGNATION Where the subsequent designation is presented through an Office. |
| Date of receipt of the subsequent designation by the Office (dd/mm/yyyy) |
| 10. SIGNATURE OF THE OFFICE PRESENTING THE REQUEST If applicable. | 10. SIGNATURE OF THE OFFICE PRESENTING THE REQUEST If applicable. |
| (a) | Name of the Office: |
| (b) | 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. | |
| (c) | E-mail address of the contact person in the Office: |
| METHOD OF PAYMENT If you want to debit the amount of the fees from your Current Account at WIPO, tick the box and provide the information under item (a). If you have already transferred those amounts to WIPO’s bank or postal account, provide as much information as possible under item (b), which would allow WIPO to identify and allocate your payment. | METHOD OF PAYMENT If you want to debit the amount of the fees from your Current Account at WIPO, tick the box and provide the information under item (a). If you have already transferred those amounts to WIPO’s bank or postal account, provide as much information as possible under item (b), which would allow WIPO to identify and allocate your payment. | METHOD OF PAYMENT If you want to debit the amount of the fees from your Current Account at WIPO, tick the box and provide the information under item (a). If you have already transferred those amounts to WIPO’s bank or postal account, provide as much information as possible under item (b), which would allow WIPO to identify and allocate your payment. | METHOD OF PAYMENT If you want to debit the amount of the fees from your Current Account at WIPO, tick the box and provide the information under item (a). If you have already transferred those amounts to WIPO’s bank or postal account, provide as much information as possible under item (b), which would allow WIPO to identify and allocate your payment. | METHOD OF PAYMENT If you want to debit the amount of the fees from your Current Account at WIPO, tick the box and provide the information under item (a). If you have already transferred those amounts to WIPO’s bank or postal account, provide as much information as possible under item (b), which would allow WIPO to identify and allocate your payment. | METHOD OF PAYMENT If you want to debit the amount of the fees from your Current Account at WIPO, tick the box and provide the information under item (a). If you have already transferred those amounts to WIPO’s bank or postal account, provide as much information as possible under item (b), which would allow WIPO to identify and allocate your payment. |
| (a) | INSTRUCTIONS TO DEBIT FROM A CURRENT ACCOUNT AT WIPO | INSTRUCTIONS TO DEBIT FROM A CURRENT ACCOUNT AT WIPO | INSTRUCTIONS TO DEBIT FROM A CURRENT ACCOUNT AT WIPO | INSTRUCTIONS TO DEBIT FROM A CURRENT ACCOUNT AT WIPO | INSTRUCTIONS TO DEBIT FROM A CURRENT ACCOUNT AT WIPO |
| The International Bureau is hereby instructed to debit the required amount of fees from a current account opened with WIPO (if this box is checked, it is not necessary to complete (b)). | The International Bureau is hereby instructed to debit the required amount of fees from a current account opened with WIPO (if this box is checked, it is not necessary to complete (b)). | The International Bureau is hereby instructed to debit the required amount of fees from a current account opened with WIPO (if this box is checked, it is not necessary to complete (b)). | The International Bureau is hereby instructed to debit the required amount of fees from a current account opened with WIPO (if this box is checked, it is not necessary to complete (b)). | The International Bureau is hereby instructed to debit the required amount of fees from a current account opened with WIPO (if this box is checked, it is not necessary to complete (b)). | |
| Holder of the account: | Holder of the account: | ||||
| Account number: | Account number: | ||||
| Identity of the party giving the instructions: | Identity of the party giving the instructions: | ||||
| (b) | BANK OR POSTAL TRANSFER | BANK OR POSTAL TRANSFER | BANK OR POSTAL TRANSFER | BANK OR POSTAL TRANSFER | BANK OR POSTAL TRANSFER |
| Identity of the party effecting the payment: | Identity of the party effecting the payment: | Identity of the party effecting the payment: | |||
| Payment received and acknowledged by WIPO | Payment received and acknowledged by WIPO | Payment received and acknowledged by WIPO | WIPO receipt number | WIPO receipt number | |
| Payment received and acknowledged by WIPO | Payment received and acknowledged by WIPO | Payment received and acknowledged by WIPO | |||
| Payment made to WIPO bank account Account name: WIPO Bank: UBS SWITZERLAND AG, ZURICH, SWITZERLAND IBAN: CH77 0024 0240 FP10 1035 6 Swift: UBSWCHZH80A | Payment made to WIPO bank account Account name: WIPO Bank: UBS SWITZERLAND AG, ZURICH, SWITZERLAND IBAN: CH77 0024 0240 FP10 1035 6 Swift: UBSWCHZH80A | Payment made to WIPO bank account Account name: WIPO Bank: UBS SWITZERLAND AG, ZURICH, SWITZERLAND IBAN: CH77 0024 0240 FP10 1035 6 Swift: UBSWCHZH80A | Payment identification | dd/mm/yyyy | |
| Payment made to WIPO bank account Account name: WIPO Bank: UBS SWITZERLAND AG, ZURICH, SWITZERLAND IBAN: CH77 0024 0240 FP10 1035 6 Swift: UBSWCHZH80A | Payment made to WIPO bank account Account name: WIPO Bank: UBS SWITZERLAND AG, ZURICH, SWITZERLAND IBAN: CH77 0024 0240 FP10 1035 6 Swift: UBSWCHZH80A | Payment made to WIPO bank account Account name: WIPO Bank: UBS SWITZERLAND AG, ZURICH, SWITZERLAND IBAN: CH77 0024 0240 FP10 1035 6 Swift: UBSWCHZH80A | |||
| Payment made to WIPO postal account (within Europe only) Account name: WIPO / OMPI SWISS POST/Postfinance, Engelhaldenstrasse 37, CH-3030 Bern IBAN: CH03 0900 0000 1200 5000 8 Swift: POFICHBE | Payment made to WIPO postal account (within Europe only) Account name: WIPO / OMPI SWISS POST/Postfinance, Engelhaldenstrasse 37, CH-3030 Bern IBAN: CH03 0900 0000 1200 5000 8 Swift: POFICHBE | Payment made to WIPO postal account (within Europe only) Account name: WIPO / OMPI SWISS POST/Postfinance, Engelhaldenstrasse 37, CH-3030 Bern IBAN: CH03 0900 0000 1200 5000 8 Swift: POFICHBE | Payment identification | dd/mm/yyyy | |
| Payment made to WIPO postal account (within Europe only) Account name: WIPO / OMPI SWISS POST/Postfinance, Engelhaldenstrasse 37, CH-3030 Bern IBAN: CH03 0900 0000 1200 5000 8 Swift: POFICHBE | Payment made to WIPO postal account (within Europe only) Account name: WIPO / OMPI SWISS POST/Postfinance, Engelhaldenstrasse 37, CH-3030 Bern IBAN: CH03 0900 0000 1200 5000 8 Swift: POFICHBE | Payment made to WIPO postal account (within Europe only) Account name: WIPO / OMPI SWISS POST/Postfinance, Engelhaldenstrasse 37, CH-3030 Bern IBAN: CH03 0900 0000 1200 5000 8 Swift: POFICHBE |
| FEE CALCULATION SHEET | FEE CALCULATION SHEET | FEE CALCULATION SHEET | FEE CALCULATION SHEET | FEE CALCULATION SHEET | FEE CALCULATION SHEET | FEE CALCULATION SHEET |
| AMOUNT OF FEES (see the Madrid System Fee Calculator) | AMOUNT OF FEES (see the Madrid System Fee Calculator) | AMOUNT OF FEES (see the Madrid System Fee Calculator) | AMOUNT OF FEES (see the Madrid System Fee Calculator) | AMOUNT OF FEES (see the Madrid System Fee Calculator) | AMOUNT OF FEES (see the Madrid System Fee Calculator) | AMOUNT OF FEES (see the Madrid System Fee Calculator) |
| Basic fee (Swiss francs) | Basic fee (Swiss francs) | Basic fee (Swiss francs) | Basic fee (Swiss francs) | Basic fee (Swiss francs) | 300 | 300 |
| Complementary fees: | Complementary fees: | Complementary fees: | Complementary fees: | Complementary fees: | Complementary fees: | Complementary fees: |
| Number of designations for which complementary fee is applicable | Number of designations for which complementary fee is applicable | Complementary fee | Total amount of the complementary fees | Total amount of the complementary fees | ||
| x | 100 Swiss francs | = | = | |||
| Individual fees (Swiss francs): | Individual fees (Swiss francs): | Individual fees (Swiss francs): | Individual fees (Swiss francs): | Individual fees (Swiss francs): | Individual fees (Swiss francs): | Individual fees (Swiss francs): |
| Designated Contracting Parties | Designated Contracting Parties | Individual fee | Designated Contracting Parties | Designated Contracting Parties | Individual fee | Individual fee |
| Total individual fees | Total individual fees | Total individual fees | = | |||
| GRAND TOTAL (Swiss francs) | GRAND TOTAL (Swiss francs) | GRAND TOTAL (Swiss francs) | = | |||
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