MM1(E) MADRID AGREEMENT AND PROTOCOL CONCERNING THE INTERNATIONAL REGISTRATION OF MARKS APPLICATION FOR INTERNATIONAL REGISTRATION GOVERNED EXCLUSIVELY BY THE MADRID AGREEMENT (Rule 9 of the Common Regulations) IMPORTANT 1. The present MM1 form is to be used where the international application is governed exclusively by the Madrid Agreement. This will be the case: – where the Office of origin (see items 1 and 3) is the Office of a Contracting State which is bound by the Madrid Agreement only, or – where the Office of origin is the Office of a Contracting State which is bound by both the Madrid Agreement and the Protocol, and where all the designated Contracting States are party to the Agreement but not to the Protocol. 2. If the international application is governed exclusively by the Madrid Protocol, the form to be used is form MM2. If it is governed by both the Madrid Agreement and the Protocol, the form to be used is form MM3. 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 MM1 – January 2009 American LegalNet, Inc. www.FormsWorkflow.com MM1(E) APPLICATION FOR INTERNATIONAL REGISTRATION GOVERNED EXCLUSIVELY BY THE MADRID AGREEMENT For use by the applicant For use by the applicant/Office This international application includes the following number of: 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: (d) Telephone: Fax: E-mail address: (e) Preferred language for correspondence: 3 English French Spanish ENTITLEMENT TO FILE (a) Check the appropriate box: (i) the applicant has a real and effective industrial or commercial establishment in the territory of 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. 4 APPOINTMENT OF A REPRESENTATIVE (if any) Name: Address: Telephone: Fax: E-mail address: MM1 – January 2009 American LegalNet, Inc. www.FormsWorkflow.com Page 2 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: MM1 – January 2009 American LegalNet, Inc. www.FormsWorkflow.com Page 3 8 COLOR(S) CLAIMED (a) The applicant claims color as a distinctive feature of the mark. 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 States): 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 States): (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: MM1 – January 2009 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 States, as follows: Please use font “Courier New” or “Times New Roman”, size 12 pt, or above Contracting State protection is sought in this Contracting State Class(es) or list of goods and services for which If the space provided is not sufficient, check the box and use a continuation sheet MM1 – January 2009 American LegalNet, Inc. www.FormsWorkflow.com Page 5 11 DESIGNATED CONTRACTING STATES Check the corresponding boxes: AL AM AT AZ BA BG BT BX BY CH CN CU CY CZ Albania Armenia Austria Azerbaijan Bosnia and Herzegovina Bulgaria Bhutan Benelux Belarus Switzerland China Cuba Cyprus Czech Republic DE DZ EG ES FR HR HU IR IT KE KG KP Germany Algeria Egypt Spain France Croatia Hungary Iran (Islamic Republic of) Italy Kenya Kyrgyzstan Democratic People’s Republic of Korea KZ Kazakhstan LI LR LS LV MA MC MD ME MK Liechtenstein Liberia Lesotho Latvia Morocco Monaco Republic of Moldova Montenegro The former Yugoslav Rep. of Macedonia MN MZ NA PL Mongolia Mozambique Namibia Poland PT RO RS RU SD SI SK SL SM SY SZ TJ UA VN Portugal Romania Serbia Russian Federation Sudan Slovenia Slovakia Sierra Leone San Marino Syrian Arab Republic Swaziland Tajikistan Ukraine Viet Nam Others: 12 SIGNATURE BY THE APPLICANT OR HIS REPRESENTATIVE (if required or allowed by the Office of origin) (dd/mm/yyyy) 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 been received, on (dd/mm/yyyy). (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: (dd/mm/yyyy) MM1 – January 2009 American LegalNet, Inc. www.FormsWorkflow.com Page 6 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 (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 Number of classes of goods and services beyond three 100 Swiss francs = Total amount of the supplementary fees Supplementary fee x 100 Swiss francs => = => 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 MM1 – January 2009 Payment identification dd/mm/yyyy Payment identification dd/mm/yyyy American LegalNet, Inc. www.FormsWorkflow.com CONTINUATION SHEET MM1 – January 2009 No : .......... of .......... American LegalNet, Inc. www.FormsWorkflow.com