MM19(E) MADRID AGREEMENT AND PROTOCOL CONCERNING THE INTERNATIONAL REGISTRATION OF MARKS REQUEST FOR THE RECORDING OF A RESTRICTION OF THE HOLDER’S RIGHT OF DISPOSAL (Rule 20 of the Common Regulations) IMPORTANT 1. This form must be presented to the International Bureau: (a) by the recorded holder or by the Office of the Contracting Party of the recorded holder, in which case the restriction may concern all or some of the designated Contracting Parties; (b) by the Office of a designated Contracting Party, in which case the restriction may concern only the territory of the said designated Contracting Party. 2. This form may be used to request the recording of a restriction of the holder’s right of disposal in respect of several international registrations of the same holder, provided that the Contracting Parties in respect of which the international registration is restricted are the same for all the international registrations concerned. 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 MM19 (E) – August 2012 American LegalNet, Inc. www.FormsWorkFlow.com MM19(E) RESTRICTION OF THE HOLDER’S RIGHT OF DISPOSAL For use by the holder or Office Holder’s reference: Office’s reference: 1 INTERNATIONAL REGISTRATION NUMBER(S) 2 NAME OF THE HOLDER (as recorded in the International Register) 3 CONTRACTING PARTY(IES) CONCERNED (check either (a) or (b)) (a) (b) AG AL AM AT AU AZ BA BG BH BQ BT BW BX BY CH CN CO CU CW CY CZ DE DK The restriction of the holder’s right of disposal is to be recorded for all the designated Contracting Parties; The restriction of the holder’s right of disposal is to be recorded for some only of the designated Contracting Parties. Indicate below, by checking the corresponding box(es), those Contracting Parties: Antigua and Barbuda Albania Armenia Austria Australia Azerbaijan Bosnia and Herzegovina Bulgaria Bahrain Bonaire, Saint Eustatius and Saba* Bhutan Botswana Benelux Belarus Switzerland China Colombia Cuba Curaçao* 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 Union Spain Finland France United Kingdom Georgia Ghana Greece Croatia Hungary Ireland Israel Iran (Islamic Republic of) Iceland Italy Japan 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 MZ NA NO OM PH PL PT Mongolia Mozambique Namibia Norway Oman Philippines Poland Portugal RO RS RU SD SE SG SI SK SL SM ST SX SY SZ TJ TM TR UA US UZ VN ZM Romania Serbia Russian Federation Sudan Sweden Singapore Slovenia Slovakia Sierra Leone San-Marino Sao Tome and Principe Sint Maarten* Syrian Arab Republic Swaziland Tajikistan Turkmenistan Turkey Ukraine United States of America Uzbekistan Viet Nam Zambia Others: * Territorial entity previously part of the Netherlands Antilles. MM19 (E) – August 2012 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 4 5 SUMMARY STATEMENT OF THE MAIN FACTS CONCERNING THE RESTRICTION (only a brief summary of the main facts concerning the restriction is to be given, and no supporting documentation should be attached to the present form. The following example may be used to draft the summary: “the holder’s right of disposal of the above-mentioned international registration(s) has been restricted in the Contracting Party(ies) indicated in heading 3, following the execution of a …………., dated ………….…, in favour of …………..”) SIGNATURE BY THE HOLDER OR HIS REPRESENTATIVE (where applicable) Holder (as recorded in the International Register) Name: Name: Signature: 6 Representative of the holder (as recorded in the International Register) Signature: OFFICE PRESENTING THE REQUEST (where applicable) Name of the Office Signature and/or stamp of the Office MM19(E) – August 2012 American LegalNet, Inc. www.FormsWorkFlow.com