MM14(E) MADRID AGREEMENT AND PROTOCOL CONCERNING THE INTERNATIONAL REGISTRATION OF MARKS REQUEST FOR AMENDMENT OF THE RECORDING OF A LICENSE (Rule 20bis of the Common Regulations) IMPORTANT 1. This form is to be used only to request the amendment of the recording of a license. Where it is intended to request the cancellation of a license, form MM15 must be submitted. 2. This request may be presented to the International Bureau directly by the holder or by the Office of the Contracting Party of the holder or by the Office of a Contracting Party with respect to which the license is granted. 3. One single form may be used to request the amendment of the recording of a license in respect of several international registrations of the same holder, provided that � the amendment applies to all, or to the same, designated Contracting Parties, for each of the international registrations concerned; and � the amendment concerns all, or the same, goods and services, for each of the international registrations concerned. 4. Where the request relates to several international registrations, a fee must be paid in respect of each international registration. 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 MM14(E) � January 2017 American LegalNet, Inc. www.FormsWorkFlow.com MM14(E) REQUEST FOR AMENDMENT OF THE RECORDING OF A LICENSE For use by the holder This request contains the following number of continuation sheets: Office's reference: For use by the Office Holder's reference: 1 INTERNATIONAL REGISTRATION NUMBER(S) (this form may be used for several international registrations of the same holder, provided that the amendment applies to all, or to the same, designated Contracting Parties and concerns all, or the same, goods and services for each of the international registrations concerned) 2 NAME OF THE HOLDER (as recorded in the International Register) 3 LICENSEE (as recorded in the International Register) Name: Address: E-mail address: By providing an e-mail address, any further correspondence from the International Bureau related to 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. American LegalNet, Inc. www.FormsWorkFlow.com MM14(E) � January 2017 MM14(E), page 2 4 CHANGE(S) (where there are several licenses recorded in respect of the international registrations(s), it should be clearly indicated which license(s) the amendment concerns) Tick the appropriate box(es): (a) (b) New name of the licensee: New address of the licensee: (c) Details of other change(s): 5 SIGNATURE BY THE HOLDER AND/OR HIS REPRESENTATIVE Holder (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: Representative of the holder (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: 6 OFFICE OF THE CONTRACTING PARTY OF THE 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 MM14(E) � January 2017 MM14(E), page 3 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: Identity of the party giving the instructions: (b) AMOUNT OF FEES (per international registration mentioned in item 1) Account number: Amount (177 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 Cr�dit Suisse, CH-1211 Geneva 70 Swift/BIC: CRESCHZZ80A Payment made to WIPO postal account (within Europe only) IBAN No. CH03 0900 0000 1200 5000 8 Swift/BIC: POFICHBE Payment identification dd/mm/yyyy Payment identification dd/mm/yyyy American LegalNet, Inc. www.FormsWorkFlow.com MM14(E) � January 2017 CONTINUATION SHEET No: .......... of .......... MM14(E) � January 2017 American LegalNet, Inc. www.FormsWorkFlow.com