MM9(E) MADRID AGREEMENT AND PROTOCOL CONCERNING THE INTERNATIONAL REGISTRATION OF MARKS REQUEST FOR THE RECORDING OF A CHANGE IN NAME AND/OR ADDRESS OF THE HOLDER (Rule 25 of the Common Regulations) IMPORTANT 1. This request may be presented to the International Bureau directly by the holder or through the Office of the Contracting Party of the holder. 2. This form is to be used only to request the recording of a change in the name and/or address of the recorded holder. The form to be used for requesting the recording of a change in the ownership of the international registration is form MM5. 3. Holders should also take this opportunity to change their contact details, namely, their address for correspondence, email address and telephone and fax numbers. However, holders wishing to change their contact details only may request so, free of charge, by sending a simple letter to the International Bureau, signed by them or by their recorded representatives. World Intellectual Property Organization 34, chemin des Colombettes 1211 Geneva 20, Switzerland Tel. (Madrid Customer Service): +41 (0)22 338 8686 Fax (Madrid Registry): +41 (0)22 740 1429 e-mail: intreg.mail@wipo.int ­ Internet: www.wipo.int MM9(E) ­ September 2016 American LegalNet, Inc. www.FormsWorkFlow.com MM9(E) REQUEST FOR THE RECORDING OF A CHANGE IN NAME AND/OR ADDRESS OF THE HOLDER For use by the holder This request contains the following number of continuation sheets: Office's reference: For use by the Office Holder's reference: 1 INTERNATIONAL REGISTRATION NUMBER(S) (this form may be used for several international registrations of the same holder) 2 NAME OF THE HOLDER (as recorded in the International Register) 3 CHANGE IN NAME AND/OR ADDRESS OF THE HOLDER (indicate the change(s) by ticking the appropriate box(es)) New name: New address: 4 NEW CONTACT DETAILS (optional) New telephone: 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. New address for correspondence: Indicate the address for correspondence, if any, and if different from the address of the holder indicated in item 3; if this item is not completed, the address for correspondence already recorded in the International Register will be automatically disregarded by the International Bureau. New fax: MM9(E) ­ September 2016 American LegalNet, Inc. www.FormsWorkFlow.com MM9(E), page 2 5 APPOINTMENT OF A (NEW) REPRESENTATIVE (optional) (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 6 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: 7 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) ­ September 2016 American LegalNet, Inc. www.FormsWorkFlow.com MM9(E), page 3 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: 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) Account number: Amount (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 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 Payment identification dd/mm/yyyy Payment identification dd/mm/yyyy MM9(E) ­ September 2016 American LegalNet, Inc. www.FormsWorkFlow.com CONTINUATION SHEET No: .......... of .......... MM9(E) ­ September 2016 American LegalNet, Inc. www.FormsWorkFlow.com