MM3(E) MADRID AGREEMENT AND PROTOCOL CONCERNING THE INTERNATIONAL REGISTRATION OF MARKS APPLICATION FOR INTERNATIONAL REGISTRATION GOVERNED BY BOTH THE MADRID AGREEMENT AND THE MADRID PROTOCOL (Rule 9 of the Common Regulations) IMPORTANT 1. The present MM3 form is to be used where the international application is governed by both the Madrid Agreement and the Protocol. This will be the case where the Office of origin (see items 1 and 3) is the Office of a Contracting Party which is bound by both the Madrid Agreement and the Protocol, and where the international application designates at least one Contracting State party to the Agreement but not to the Protocol and at least one Contracting Party to the Protocol, irrespective of whether or not that Contracting Party is also party to the Agreement. 2. If the international application is governed exclusively by the Madrid Agreement, the form to be used is form MM1. If it is governed exclusively by the Madrid Protocol, the form to be used is form MM2. 3. This form must be sent to the Office of origin. It must not be sent directly to the International Bureau. World Intellectual Property Organization 34, chemin des Colombettes, P.O. Box 18, 1211 Geneva 20, Switzerland Tel.: (41-22) 338 9111 Fax (International Trademark Registry): (41-22) 740 1429 e-mail: intreg.mail@wipo.int – Internet: http://www.wipo.int MM3(E) – August 2012 American LegalNet, Inc. www.FormsWorkFlow.com MM3(E) APPLICATION FOR INTERNATIONAL REGISTRATION GOVERNED BY BOTH THE MADRID AGREEMENT AND THE MADRID PROTOCOL For use by the applicant/Office For use by the applicant This international application includes the following number of: – continuation sheet(s): – MM17 form(s): Applicant’s reference: Office’s reference: 1 CONTRACTING STATE WHOSE OFFICE IS THE OFFICE OF ORIGIN 2 APPLICANT (a) Name: (b) Address: (c) Address for correspondence: Fax: (d) Telephone : E-mail address: (e) Preferred language for correspondence: English French Spanish (f) Other indications (as may be required by certain designated Contracting Parties; for example, if the United States of America is designated, it is necessary to include these indications): (i) if the applicant is a natural person, nationality of applicant: (ii) if the applicant is a legal entity: – – 3 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: ENTITLEMENT TO FILE (a) Check the appropriate box: (i) the applicant has a real and effective industrial or commercial establishment in the Contracting State mentioned in item 1; (ii) if there is no such establishment in a Contracting State of the Agreement, the applicant is domiciled in the Contracting State mentioned in item 1; (iii) if there is no such establishment or domicile in a Contracting State of the Agreement, the applicant is a national of the Contracting State mentioned in item 1. (b) Where the address of the applicant, given in item 2(b), is not in the territory of the Contracting State mentioned in item 1, indicate in the space provided below: (i) if the box corresponding to paragraph (a)(i) of the present item has been checked, the address of the applicant’s industrial or commercial establishment in that State, or, (ii) if the box corresponding to paragraph (a)(ii) of the present item has been checked, the domicile of the applicant in that State. MM3(E) – August 2012 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 4 APPOINTMENT OF A REPRESENTATIVE (if any) Name: Address: Telephone: Fax: E-mail address: 5 BASIC REGISTRATION Basic registration number: (dd/mm/yyyy) Date of the basic registration: 6 PRIORITY CLAIMED The applicant claims the priority of the earlier filing mentioned below: Office of earlier filing: Number of earlier filing (if available): (dd/mm/yyyy) Date of earlier filing: If the earlier filing does not relate to all the goods and services listed in item 10 of this form, indicate in the space provided below the goods and services to which it does relate: If several priorities are claimed, check box and use a continuation sheet giving the above required information for each priority claimed. 7 THE MARK (a) Place the reproduction of the mark, as it appears in the basic registration, in the square below. (b) Where the reproduction in item (a) is in black and white and color is claimed in item 8, place a color reproduction of the mark in the square below. (c) The applicant declares that he wishes the mark to be considered as a mark in standard characters. (d) The mark consists of a color or a combination of colors as such Where the Office of origin has addressed this form by facsimile, the present space must be completed before addressing the original of this page to the International Bureau. Number of basic registration or Office reference as shown on the first page of this form: Signature by the Office of origin: MM3(E) – August 2012 American LegalNet, Inc. www.FormsWorkFlow.com Page 3 8 COLOR(S) CLAIMED The applicant claims color as a distinctive feature of the mark. (a) Color or combination of colors claimed: (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): 9 MISCELLANEOUS INDICATIONS (a) Transliteration of the mark (this information is compulsory where the mark consists of or contains matter in characters other than Latin characters, or numerals other than Arabic or Roman numerals): (b) Translation of the mark (as may be required by certain designated Contracting Parties): (i) into English: (ii) into French: (iii) into Spanish: (c) The words contained in the mark have no meaning (and therefore cannot be translated). (d) Where applicable, check the relevant box or boxes below: Three-dimensional mark Sound mark Collective mark, certification mark, or guarantee mark (e) Description of the mark (where applicable): (f) Verbal elements of the mark (where applicable): (g) The applicant declares that he wishes to disclaim protection for the following element(s) of the mark: MM3(E) – August 2012 American LegalNet, Inc. www.FormsWorkFlow.com Page 4 10 GOODS AND SERVICES (a) Indicate below the goods and services for which the international registration is sought: Please use font “Courier New” or “Times New Roman”, size 12 pt, or above Class (b) Goods and services The applicant wishes to limit the list of goods and services in respect of one or more designated Contracting Parties, as follows: Please use font “Courier Contracting Party New” or “Times New Roman”, size 12 pt, or above Class(es) or list of goods and services for which protection is sought in this Contracting Party If the space provided is not sufficient, check the box and use a continuation sheet MM3(E) – August 2012 American LegalNet, Inc. www.FormsWorkFlow.com Page 5 11 DESIGNATED CONTRACTING PARTIES (Information concerning national or regional procedures for each Contracting Party designated may be found at the following website: http://www.wipo.int/madrid/en/members/ipoffices_info.html. Additional information may be found in the information notices available at: http://www.wipo.int/madrid/en/notices/) Check the corresponding boxes: AG AL AM AT AU AZ BA BG BH BQ BT BW BX BY CH CN CO CU CW CY CZ DE DK Antigua and Barbuda Albania Armenia Austria Australia Azerbaijan Bosnia and Herzegovina Bulgaria Bahrain Bonaire, Saint Eustatius and Saba5 Bhutan Botswana Benelux Belarus Switzerland China Colombia Cuba4 Curacao5 Cyprus Czech Republic Germany Denmark DZ EE EG EM ES FI FR GB GE GH GR HR HU IE IL IR IS IT JP KE KG KP Algeria Estonia Egypt European Union1 Spain Finland France United Kingdom2 Georgia Ghana4 Greece Croatia Hungary Ireland2 Israel Iran (Islamic Republic of) Iceland Italy Japan4 Kenya Kyrgyzstan Democratic People’s Republic of Korea KR Republic of Korea KZ Kazakhstan 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 MZ NA NO OM PH PL PT Mongolia Mozambique Namibia Norway Oman Philippines Poland Portugal Romania Serbia Russian Federation Sudan Sweden Singapore2 Slovenia Slovakia Sierra Leone San Marino Sao Tome and Principe Sint Maarten5 Syrian Arab Republic Swaziland Tajikistan Turkmenistan Turkey Ukraine United States of America3 UZ Uzbekistan VN Viet Nam ZM Zambia RO RS RU SD SE SG SI SK SL SM ST SX SY SZ TJ TM TR UA US Others: 1 If the European Union is designated, it is compulsory to indicate a second language before the Office of the European Union, among the following (check Spanish Italian German French one box only): 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 international application. 2 By designating Ireland, Singapore or the United Kingdom, the applicant declares that he has the intention that the mark will be used by him or with his consent in that country in connection with the goods and services identified in this application. 3 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. 4 Cuba, Ghana and Japan have made a notification under Rule 34(3)(a) of the Common Regulations. Their respective individual fees are payable in two parts. Therefore, if Cuba, Ghana or Japan is designated, only the first part of the applicable individual fee is payable at the time of filing the present international application. The second part will have to be paid only if the Office of the Contracting Party concerned 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. 5 Territorial entity previously part of the former Netherlands Antilles. 12 SIGNATURE BY THE APPLICANT OR HIS REPRESENTATIVE (if required or allowed by the Office of origin) (dd/mm/yyyy) MM3(E) – August 2012 American LegalNet, Inc. www.FormsWorkFlow.com Page 6 13 CERTIFICATION AND SIGNATURE OF THE INTERNATIONAL APPLICATION BY THE OFFICE OF ORIGIN (a) Certification The Office of origin certifies (i) that the request to present this application was received, or, as provided in Rule 11(1) of the Regulations, is deemed to have (dd/mm/yyyy). been received, on (ii) that the applicant named in item 2 is the same as the holder named in the basic registration mentioned in item 5, that any indication given in item 7(d), 9(d) or 9(e) appears also in the basic registration, that the mark in item 7(a) is the same as in the basic registration, that, if color is claimed as a distinctive feature of the mark in the basic registration, the same claim is included in item 8 or that, if color is claimed in item 8 without having being claimed in the basic registration, the mark in the basic registration is in fact in the color or combination of colors claimed, and that the goods and services listed in item 10 are covered by the list of goods and services appearing in the basic registration. Where the international application is based on two or more basic registrations, the above declaration shall be deemed to apply to all those basic registrations. (b) Office’s signature: Date of signature: MM3(E) – August 2012 (dd/mm/yyyy) American LegalNet, Inc. www.FormsWorkFlow.com Page 7 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)). Account number: Holder of the account: Identity of the party giving the instructions: (b) AMOUNT OF FEES (see Fee Calculator: www.wipo.int/madrid/en/fees/calculator.jsp) Basic fee: 653 Swiss francs if the reproduction of the mark is in black and white only and 903 Swiss francs if there is a reproduction in color. (For international applications filed by applicants whose country of origin is a Least Developed Country, in accordance with the list established by the United Nations (www.wipo.int/ldcs/en/country), 65 Swiss francs if the reproduction is in black and white only and 90 Swiss francs if there is a reproduction in color.) Complementary and supplementary fees: Number of designations for which complementary fee is applicable Total amount of the complementary fees Complementary fee x 100 Swiss francs Number of classes of goods and services beyond three = Total amount of the supplementary fees Supplementary fee x 100 Swiss francs => = => Individual fees (Swiss francs): Designated Contracting Parties Individual fee Designated Contracting Parties Total individual fees Individual fee => GRAND TOTAL (Swiss francs) (c) METHOD OF PAYMENT Identity of the party effecting the payment: WIPO receipt number Payment received and acknowledged by WIPO Payment made to WIPO bank account IBAN No. CH51 0483 5048 7080 8100 0 Credit Suisse, CH-1211 Geneva 70 Swift/BIC: CRESCHZZ80A Payment made to WIPO postal account IBAN No. CH03 0900 0000 1200 5000 8 Swift/BIC: POFICHBE MM3(E) – August 2012 Payment identification dd/mm/yyyy Payment identification dd/mm/yyyy American LegalNet, Inc. www.FormsWorkFlow.com CONTINUATION SHEET MM3(E) – August 2012 No : .......... of .......... 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