MM22(E) 226 February 2019 MM22(E) MADRID AGREEMENT AND PROTOCOL CONCERNING THE INTERNATIONAL REGISTRATION OF MARKS REQUEST FOR THE DIVISION OF AN INTERNATIONAL REGISTRATION (Rule 27bis of the Common Regulations) IMPORTANT This request must be signed and presented to the International Bureau by the Office of the Contracting Party in respect of which the international registration is to be divided. 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 MM22(E) 226 February 2019 MM22(E) REQUEST FOR THE DIVISION OF AN INTERNATIONAL REGISTRATION For the holder This request contains the following number of continuation sheets: Holder222s reference: For the Office Office222s reference: CONTRACTING PARTY OF THE OFFICE PRESENTING THE REQUEST (name of the Contracting Party in respect of which the international registration is to be divided) NAME OF THE OFFICE PRESENTING THE REQUEST (must be the Office of the Contracting Party indicated in item 1) INTERNATIONAL REGISTRATION NUMBER (international registration to be divided in respect of the Contracting Party indicated in item 1) NAME OF THE HOLDER (as recorded in the International Register) GOODS AND SERVICES FOR WHICH DIVISION IS TO BE RECORDED (names of the goods and services to be set apart in the divisional international registration, grouped in the appropriate classes) If the space provided above is not sufficient, check the box and use a continuation sheet SIGNATURE BY THE HOLDER OR THE REPRESENTATIVE (only when the Office presenting the request requires the holder to do so) Holder Representative of the holder (as recorded in the International Register) (before the Office presenting the request) 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: 3 4 1 2 6 5 American LegalNet, Inc. www.FormsWorkFlow.com MM22(E), page 2 MM22(E) 226 February 2019 STATEMENT (optional, to be filled only by the Office presenting the request) After the recording of the division of the international registration, the statement indicated below shall be recorded under the divisional international registration for the goods and services listed in item 5 (please, check only one box) A statement of interim status of the mark in accordance with Rule 18bis(1) of the Common Regulations. A statement of grant of protection in accordance with Rule 18ter of the Common Regulations. SIGNATURE BY THE OFFICE PRESENTING THE REQUEST (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: 8 7 American LegalNet, Inc. www.FormsWorkFlow.com MM22(E), page 3 MM22(E) 226 February 2019 PAYMENT INFORMATION (a) AMOUNT OF FEE 177 Swiss francs (b) INSTRUCTIONS TO DEBIT FROM A CURRENT ACCOUNT (If the holder wants to debit the required amount from a current account opened with the International Bureau, please, tick the box below and indicate the following) The International Bureau is hereby instructed to debit the required amount of fees from a current account opened with the International Bureau Holder of the account: Account number: Identity of the party giving the instructions: (c) METHOD OF PAYMENT ( If the holder has already transferred the required amount to a WIPO bank or postal account, please, indicate the following ) Identity of the party effecting the payment: Payment received and acknowledged by WIPO WIPO receipt number Payment made to WIPO bank account IBAN No. CH51 0483 5048 7080 8100 0 Cr351dit Suisse, CH-1211 Geneva 70 Swift/BIC: CRESCHZZ80A Payment identification dd/mm/yyyy 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 American LegalNet, Inc. www.FormsWorkFlow.com MM22(E) 226 February 2019 CONTINUATION SHEET No: .......... of .......... American LegalNet, Inc. www.FormsWorkFlow.com