MM19(E) 226 June 2019 MM19(E) MADRID AGREEMENT AND PROTOCOL CONCERNING THE INTERNATIONAL REGISTRATION OF MARKS REQUEST FOR THE RECORDING OF A RESTRICTION OF THE HOLDER222S 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 through the Office of the Contracting Party of the recorded holder, in which case the designated Contracting Parties concerned should be indicated; (b) through 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 holder222s 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. This cover page must not be sent to the International Bureau. Madrid System 226 Contacts Madrid Customer Service opening hours: Monday 226 Friday, 9:00 a.m. to 6:00 p.m. (Geneva time) Telephone: + 41 22 338 86 86 Inquiries / submitting forms: http://www.wipo.int/madrid/en/contact/ Mailing address Madrid Operations Division Madrid Registry Brands and Designs Sector World Intellectual Property Organization (WIPO) 34, Chemin des Colombettes 1211 Geneva 20 Switzerland American LegalNet, Inc. www.FormsWorkFlow.com MM19(E) 226 June 2019 MM19(E) RESTRICTION OF THE HOLDER222S RIGHT OF DISPOSAL For use by the holder Holder222s reference: For use by the Office Office222s reference: INTERNATIONAL REGISTRATION NUMBER(S) (this form may be used for several international registrations in the name of the same holder, provided that the Contracting Parties in respect of which the international registration is restricted is the same for all of the international registrations concerned) NAME OF THE HOLDER (as recorded in the International Register) 1 2 American LegalNet, Inc. www.FormsWorkFlow.com MM19(E), page 2 MM19(E) 226 June 2019 CONTRACTING PARTY(IES) CONCERNED (check either (a) or (b)) (a) The restriction of the holder222s right of disposal is to be recorded for all the designated Contracting Parties; (b) The restriction of the holder222s 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 P arties: AF Afghanistan AG Antigua and Barbuda AL Albania AM Armenia AT Austria AU Australia AZ Azerbaijan BA Bosnia and Herzegovina BG Bulgaria BH Bahrain BN Brunei Darussalam BQ Bonaire, Saint Eustatius and Saba1 BT Bhutan BW Botswana BX Benelux BY Belarus CA Canada CH Switzerland CN China CO Colombia CU Cuba CW Cura347ao1 CY Cyprus CZ Czech Republic DE Germany DK Denmark DZ Algeria EE Estonia EG Egypt EM European Union2 ES Spain FI Finland FR France GB United Kingdom GE Georgia GH Ghana GM Gambia GR Greece HR Croatia HU Hungary ID Indonesia IE Ireland IL Israel IN India IR Iran (Islamic Republic of) IS Iceland IT Italy JP Japan KE Kenya KG Kyrgyzstan KH Cambodia KP Democratic People222s Republic of Korea KR Republic of Korea KZ Kazakhstan LA Lao People222s Democratic Republic LI Liechtenstein LR Liberia LS Lesotho LT Lithuania LV Latvia MA Morocco MC Monaco MD Republic of Moldova ME Montenegro MG Madagascar MK North Macedonia MN Mongolia MW Malawi MX Mexico MZ Mozambique NA Namibia NO Norway NZ New Zealand OA African Intellectual Property Organization (OAPI)3 OM Oman PH Philippines PL Poland PT Portugal RO Romania RS Serbia RU Russian Federation RW Rwanda SD Sudan SE Sweden SG Singapore SI Slovenia SK Slovakia SL Sierra Leone SM San-Marino ST Sao Tome and Principe SX Sint Maarten (Dutch part)1 SY Syrian Arab Republic SZ Eswatini TH Thailand TJ Tajikistan TM Turkmenistan TN Tunisia TR Turkey UA Ukraine US United States of America UZ Uzbekistan VN Viet Nam WS Samoa ZM Zambia ZW Zimbabwe Others: 1 Territorial entity previously part of the Netherlands Antilles. 2 The designation of the European Union covers the following Member States: Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, United Kingdom. 3 The designation of the African Intellectual Property Organization covers the following Member States: Benin, Burkina Faso, Cameroon, Central African Republic, Chad, Comoros, Congo, C364te d222Ivoire, Equatorial Guinea, Gabon, Guinea, Guinea-Bissau, Mali, Mauritania, Niger, Senegal, Togo. 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: 223the holder222s 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 205205205205., dated 205205205205.205, in favour of 205205205205..224) 3 4 American LegalNet, Inc. www.FormsWorkFlow.com MM19(E), page 3 MM19(E) 226 June 2019 SIGNATURE BY THE HOLDER AND/OR HIS REPRESENTATIVE Holder Representative of the holder (as recorded in the International Register) (as recorded in the International Register) By signing this form, I declare that I am entitled to By signing this form, I declare that I am entitled to sign it under the applicable law: sign it under the applicable law: Name: Name: Signature: Signature: OFFICE OF THE CONTRACTING PARTY 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: 6 5 American LegalNet, Inc. www.FormsWorkFlow.com