PATENT COOPERATION TREATY PCT To: CREDIT CARD PAYMENT TO THE INTERNATIONAL BUREAU OF SUPPLEMENTARY SEARCH FEES The International Bureau of WIPO PCT Receiving and Processing Team 34, chemin des Colombettes 1211 Geneva 20 Switzerland Applicant’s or agent’s file reference Facsimile No. +41 22 910 06 10 International application No. (if known) International filing date (day/month/year) (if known) Applicant or agent’s name and address Telephone No. Facsimile No. The applicant or agent hereby requests the International Bureau to debit the following amount from the credit card identified below. Amount (CHF): ______________________________ (Swiss franc only) Credit Card Information Credit card: Visa MasterCard/ Eurocard American Express Credit card number: _________________________________________ Credit card expiration date: ___________________________________ (month/year) Name as it appears on credit card: ___________________________________________________________________ Credit card billing address: ________________________________________________________________________ Cardholder’s signature: ______________________________________ Date: ______________________________ Warning The International Bureau will not include this form among the documents available for public inspection. The International Bureau will not accept payment by credit card if the cardholder submits credit card information on any form or document other than this form, and will not be liable for the consequences of any such submission. Failure to use this form may result in the release of your credit card information. Form PCT/IB/380 (January 2009) American LegalNet, Inc. www.FormsWorkflow.com