MM12(E) MADRID AGREEMENT AND PROTOCOL CONCERNING THE INTERNATIONAL REGISTRATION OF MARKS APPOINTMENT OF A REPRESENTATIVE IMPORTANT 1. 2. The use of this form is not compulsory. It is made available for the convenience of holders of international registrations. This request may be presented to the International Bureau by the applicant, holder or representative, in which case it must be signed by the applicant or holder or through the Office of the Contracting Party of the holder, in which case it must be signed either by the applicant or holder or by the Office through which it is presented. This form may relate to one or more international applications and/or registrations of the same applicant and/or holder. 3. 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 MM12(E) � January 2017 American LegalNet, Inc. www.FormsWorkFlow.com MM12(E) APPOINTMENT OF A REPRESENTATIVE For use by the applicant/holder This request contains the following number of continuation sheets: Office's reference: For use by the Office Applicant/holder's reference: 1 NAME OF THE APPLICANT AND/OR HOLDER (as mentioned in the international application(s) and/or as recorded in the International Register) 2 1 INTERNATIONAL APPLICATION(S)'S REFERENCE(S) AND/OR INTERNATIONAL REGISTRATION NUMBER(S) (this form may be used for several international applications and/or registrations of the same applicant and/or holder) For international applications indicate the basic mark(s), basic application/registration number(s) and date(s) and the filing date of the international application(s) For international registrations indicate the international registrations concerned by the appointment of the representative: 3 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 application(s) and its/their resulting international registration(s) and/or 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. 4 SIGNATURE BY THE APPLICANT AND/OR HOLDER (as indicated in the international application(s) and/or 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: MM12(E) � January 2017 American LegalNet, Inc. www.FormsWorkFlow.com MM12(E), page 2 5 OFFICE OF THE CONTRACTING PARTY OF THE APPLICANT AND/OR 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: American LegalNet, Inc. www.FormsWorkFlow.com MM12(E) � January 2017 CONTINUATION SHEET No: .......... of .......... MM12(E) � January 2017 American LegalNet, Inc. www.FormsWorkFlow.com