MM16(E) MADRID AGREEMENT AND PROTOCOL CONCERNING THE INTERNATIONAL REGISTRATION OF MARKS SUBSEQUENT DESIGNATION RESULTING FROM CONVERSION (EUROPEAN COMMUNITY) IMPORTANT This request must be presented to the International Bureau through the intermediary of the Office of the European Community: the Office for Harmonization in the Internal Market (Trade Marks and Designs) (“OHIM”) 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 MM16(E) – IX.08 American LegalNet, Inc. www.FormsWorkflow.com MM16(E) SUBSEQUENT DESIGNATION RESULTING FROM CONVERSION For use by the holder For use by the holder/Office This subsequent designation contains the following number of Holder’s reference: continuation sheets: Office’s reference: 1 2 INTERNATIONAL REGISTRATION NUMBER HOLDER (as recorded in the International Register) Name: Address: 3 APPOINTMENT OF A REPRESENTATIVE (do not complete this item if there is no change in the representative already recorded in the International Register) Name: Address: Telephone: Fax: E-mail address: SIGNATURE OF THE HOLDER APPOINTING THE ABOVE (NEW) REPRESENTATIVE 4 GROUND FOR THE CONVERSION OF THE DESIGNATION OF THE EUROPEAN COMMUNITY The designation of the European Community in the international registration indicated in item 1 (tick the appropriate box): has been the subject of a final refusal has not been renewed and the possibility to renew the mark has lapsed has been the subject of a partial cancellation has been the subject of an invalidation has been the subject of a renunciation 5 DESIGNATED CONTRACTING PARTIES AT BG BX CY CZ DE DK 1 Austria Bulgaria Benelux Cyprus Czech Republic Germany Denmark EE ES FI FR GB GR Estonia Spain Finland France United Kingdom1 Greece HU IE IT LT LV Hungary Ireland1 Italy Lithuania Latvia PL PT RO SE SI SK Poland Portugal Romania Sweden Slovenia Slovakia By designating Ireland and/or the United Kingdom, the holder 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 the present subsequent designation. MM16(E) – IX.08 American LegalNet, Inc. www.FormsWorkflow.com Page 2 6 GOODS AND SERVICES (check only one box) (a) the subsequent designation is made, in respect of all the Contracting Parties designated in item 5, for all the goods and services covered by the designation of the European Community; or (b) the subsequent designation concerns all the Contracting Parties designated in item 5 but only some of the goods and services covered by the designation of the European Community. The goods and services (which must be grouped in the appropriate class(es)) concerned are listed in the continuation sheet; or (c) the subsequent designation is made, in respect of some of the Contracting Parties designated in item 5, for only part of the goods and services covered by the designation of the European Community; those Contracting Parties and the goods and services concerned (which must be grouped in the appropriate class(es)) are indicated below. In respect of the other Contracting Parties designated in item 5, the subsequent designation concerns all the goods and services covered by the designation of the European Community. If the space provided is not sufficient, check the box and use a continuation sheet 7 SIGNATURE BY THE OFFICE Name of the Office: Signature and/or stamp of the Office: MM16(E) – IX.08 American LegalNet, Inc. www.FormsWorkflow.com 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: Account number: Identity of the party giving the instructions: (b) AMOUNT OF FEES; METHOD OF PAYMENT Basic fee (300 Swiss francs) Complementary fees: Number of designations for which complementary fee is applicable Total amount of the complementary fees Complementary fee 100 Swiss francs x = => Individual fees (Swiss francs): Designated Contracting Parties Individual fee Designated Contracting Parties Total individual fees Individual fee => GRAND TOTAL (Swiss francs) 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 MM16(E) – IX.08 Payment identification dd/mm/yyyy Payment identification dd/mm/yyyy American LegalNet, Inc. www.FormsWorkflow.com CONTINUATION SHEET MM16(E) – IX.08 No: .......... of .......... 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