MM4(E) MADRID AGREEMENT AND PROTOCOL CONCERNING THE INTERNATIONAL REGISTRATION OF MARKS DESIGNATION SUBSEQUENT TO THE INTERNATIONAL REGISTRATION (Rule 24 of the Common Regulations) IMPORTANT 1. This subsequent designation must be presented to the International Bureau: (a) through the Office of the Contracting Party of the holder where any Contracting Party is designated under the Madrid Agreement; (b) through the Office of origin where Rule 7(1) (as in force before October 4, 2001) applies; (c) in all other cases, either directly by the holder or by the Office of the Contracting Party of the holder. 2. The period of protection of a subsequent designation expires on the same date as the international registration to which it relates. 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 MM4(E) – August 2012 American LegalNet, Inc. www.FormsWorkFlow.com MM4(E) DESIGNATION SUBSEQUENT TO THE INTERNATIONAL REGISTRATION For use by the holder/Office For use by the holder This subsequent designation includes the following number of: – continuation sheet(s): – MM17 form(s): Holder’s reference: Office’s reference: 1 INTERNATIONAL REGISTRATION NUMBER 2 HOLDER OF THE INTERNATIONAL REGISTRATION (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 MM4(E) – August 2012 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 4 CONTRACTING PARTIES DESIGNATED SUBSEQUENTLY (Information concerning national or regional procedures for each Contracting Party designated may be found at the following website: http://www.wipo.int/madrid/en/members/ipoffices_info.html. Additional information may be found in the information notices available at: http://www.wipo.int/madrid/en/notices/) Check the corresponding boxes: AG AL AM AT AU AZ BA BG BH BQ BT BW BX BY CH CN CO CU CW CY CZ DE DK Others: 1 Antigua and Barbuda Albania Armenia Austria Australia Azerbaijan Bosnia and Herzegovina Bulgaria Bahrain Bonaire, Saint Eustatius and Saba5 Bhutan Botswana Benelux Belarus Switzerland China Colombia Cuba4 Curaçao5 Cyprus Czech Republic Germany Denmark DZ EE EG EM ES FI FR GB GE GH GR HR HU IE IL IR IS IT JP KE KG KP Algeria Estonia Egypt European Union1 Spain Finland France United Kingdom2 Georgia Ghana4 Greece Croatia Hungary Ireland2 Israel Iran (Islamic Republic of) Iceland Italy Japan4 Kenya Kyrgyzstan Democratic People’s Republic of Korea KR Republic of Korea KZ Kazakhstan LI Liechtenstein LR Liberia LS Lesotho LT Lithuania LV Latvia MA Morocco MC Monaco MD Republic of Moldova ME Montenegro MG Madagascar MK The former Yugoslav Rep. of Macedonia MN Mongolia MZ Mozambique NA Namibia NO Norway OM Oman PH Philippines PL Poland PT Portugal Romania Serbia Russian Federation Sudan Sweden Singapore2 Slovenia Slovakia Sierra Leone San Marino Sao Tome and Principe Sint Maarten5 Syrian Arab Republic Swaziland Tajikistan Turkmenistan Turkey Ukraine United States of America3 UZ Uzbekistan VN Viet Nam ZM Zambia RO RS RU SD SE SG SI SK SL SM ST SX SY SZ TJ TM TR UA US If the European Union is designated, it is compulsory to indicate a second language before the Office of the European Union. The second language must be chosen from among the following five languages, but may not be the language of the international application from which the international registration indicated in item 1 resulted, regardless of the language of the present subsequent designation. Thus, for example, if the international application was filed in French and this subsequent designation is in English, French may not be selected as the second language (check one box only): French German Italian Spanish Moreover, if the holder wishes to claim the seniority of an earlier mark registered in, or for, a Member State of the European Union, the official form MM17 must be annexed to the present subsequent designation. 2 By designating Ireland, Singapore 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. 3 If the United States of America is designated, it is compulsory to annex to the present subsequent designation the official form (MM18) containing the declaration of intention to use the mark required by this Contracting Party. Item 6(a) of the present form should also be completed. 4 Cuba, Ghana and Japan have made a notification under Rule 34(3)(a) of the Common Regulations. Their respective individual fees are payable in two parts. Therefore, if Cuba, Ghana or Japan is designated, only the first part of the applicable individual fee is payable at the time of filing the present international application. The second part will have to be paid only if the Office of the Contracting Party concerned is satisfied that the mark which is the subject of the international registration qualifies for protection. The date by which the second part must be paid, and the amount due, will be notified to the holder of the international registration at a later stage. 5 Territorial entity previously part of the former Netherlands Antilles. 5 GOODS AND SERVICES CONCERNED BY THE SUBSEQUENT DESIGNATION (check only one box) (a) the subsequent designation is made, in respect of all the Contracting Parties designated in item 4, for all the goods and services listed in the international registration indicated in item 1; or (b) the subsequent designation is made, in respect of all the Contracting Parties designated in item 4, only for those goods and services listed in the continuation sheet (which must be grouped in the appropriate class(es)); or (c) the subsequent designation is only for those goods and services listed in the continuation sheet in respect of the Contracting Parties identified in the said continuation sheet; in respect of the other Contracting Parties designated in item 4, the subsequent designation is for all the goods and services listed in the international registration identified in item 1. MM4(E) – August 2012 American LegalNet, Inc. www.FormsWorkFlow.com Page 3 6 MISCELLANEOUS INDICATIONS (a) Indications concerning the holder (as may be required by certain designated Contracting Parties; for example, if the United States of America is designated, it is necessary to include these indications): (i) if the holder is a natural person, nationality of the holder: (ii) if the holder is a legal entity: – legal nature of the legal entity: – State and, where applicable, territorial unit within that State, under the law of which the legal entity is organized: (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 Parties): (c) Translation of the mark (as may be required by certain designated Contracting Parties): (i) into English: (ii) into French: (iii) into Spanish: (d) 7 If the words contained in the mark have no meaning (and therefore cannot be translated), check this box DATE OF EFFECT OF THE SUBSEQUENT DESIGNATION (if neither of these boxes is checked, the date of this subsequent designation will be the date of its receipt by the International Bureau or, if it has been presented through the intermediary of an Office, the date of receipt by that Office) (a) (b) 8 this subsequent designation shall take effect immediately after the renewal of the international registration indicated in item 1; this subsequent designation shall take effect immediately after the recording in the International Register of the following change concerning the international registration indicated in item 1 (specify the change): SIGNATURE BY THE HOLDER OR HIS REPRESENTATIVE Holder (as recorded in the International Register) Representative of the holder (as recorded in the International Register) Name: Name: Signature: Signature: MM4(E) – August 2012 American LegalNet, Inc. www.FormsWorkFlow.com Page 4 9 DATE OF RECEIPT AND DECLARATION BY THE OFFICE (where the subsequent designation is presented through an Office) (a) Date of receipt of the subsequent designation by the Office: (dd/mm/yyyy) (b) Declaration that the basic application has matured to registration: Only applicable where: – the subsequent designation relates to an international registration which was based on a basic application; – the present subsequent designation is the first designating a Contracting Party under the Agreement, and – it is presented through the Office of origin. (i) Date of the registration resulting from the basic application: (dd/mm/yyyy) (ii) Number of the registration resulting from the basic application: 10 OFFICE PRESENTING THE SUBSEQUENT DESIGNATION (if applicable) Name of the Office: Signature and/or stamp of the Office: MM4(E) – August 2012 American LegalNet, Inc. www.FormsWorkFlow.com Page 5 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)). Account number: Holder of the account: Identity of the party giving the instructions: (b) AMOUNT OF FEES; METHOD OF PAYMENT Basic fee (Swiss francs) 300.-- Complementary fees: Number of designations for which complementary fee is applicable Total amount of the complementary fees Complementary fee x 100 Swiss francs = => 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 MM4(E) – August 2012 Payment identification dd/mm/yyyy Payment identification dd/mm/yyyy American LegalNet, Inc. www.FormsWorkFlow.com CONTINUATION SHEET MM4(E) – August 2012 No: .......... of .......... 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