MM10(E) MADRID AGREEMENT AND PROTOCOL CONCERNING THE INTERNATIONAL REGISTRATION OF MARKS REQUEST FOR THE RECORDING OF A CHANGE IN NAME AND/OR ADDRESS OF THE REPRESENTATIVE (Rule 25 of the Common Regulations) IMPORTANT 1. This request may be presented to the International Bureau directly by the holder or through the Office of the Contracting Party of the holder. 2. This form is to be used only to request the recording of a change in the name or address of the recorded representative and not to appoint a new representative. 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 MM10(E) ­ September 2016 American LegalNet, Inc. www.FormsWorkFlow.com MM10(E) REQUEST FOR THE RECORDING OF A CHANGE IN NAME AND/OR ADDRESS OF THE REPRESENTATIVE For use by the representative This request contains the following number of continuation sheets: Office's reference: For use by the Office Representative's reference: 1 INTERNATIONAL REGISTRATION NUMBER(S) (this form may be used for several international registrations of the same representative) 2 NAME OF THE REPRESENTATIVE (as recorded in the International Register) Name: Address: 3 CHANGE IN NAME AND/OR ADDRESS OF THE REPRESENTATIVE (indicate the change(s)) New name: New address: New telephone: New e-mail address: New fax: 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. 4 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: MM10(E) ­ September 2016 American LegalNet, Inc. www.FormsWorkFlow.com MM10(E), page 2 5 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: MM10(E) ­ September 2016 American LegalNet, Inc. www.FormsWorkFlow.com CONTINUATION SHEET No: .......... of .......... MM10(E) ­ September 2016 American LegalNet, Inc. www.FormsWorkFlow.com