MM5(E) MADRID AGREEMENT AND PROTOCOL CONCERNING THE INTERNATIONAL REGISTRATION OF MARKS REQUEST FOR THE RECORDING OF A CHANGE IN OWNERSHIP (Rule 25 of the Common Regulations) IMPORTANT 1. If the present request relates to a total change in ownership, as provided for in item 6(a), this form may be used for several international registrations in the name of the same holder. 2. If the present request relates to a partial change in ownership, as provided for in item 6(b), this form may only be used to request the recording of a change in ownership for a single international registration. 3. This request may be presented to the International Bureau directly by the recorded holder, or by the Office of the Contracting Party of the recorded holder or by the Office of the Contracting Party of the new owner (the transferee). 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 MM5(E) – I.08 American LegalNet, Inc. www.FormsWorkflow.com MM5(E) REQUEST FOR THE RECORDING OF A CHANGE IN OWNERSHIP For use by the holder/Office For use by the holder This request contains the following number of continuation sheets: Holder’s reference: Office’s reference: 1 2 3 INTERNATIONAL REGISTRATION NUMBER(S) (several international registration numbers may be indicated below, provided that all registrations concerned are the subject of a total change in ownership, as provided for in item 6(a)) NAME OF THE HOLDER (transferor) (as recorded in the International Register) NEW OWNER (transferee) (a) Name: (b) Address: (c) Address for correspondence: (d) Telephone: Fax: E-mail address: 4 ENTITLEMENT OF THE TRANSFEREE TO BE THE HOLDER OF THE INTERNATIONAL REGISTRATION (a) Indicate in the appropriate space(s): (i) the name of the Contracting State of which the transferee is a national; and/or, (ii) the name of the State member of a Contracting Organization of which the transferee is a national; and/or, (iii) the name of the Contracting Party in the territory of which the transferee is domiciled; and/or, (iv) the name of the Contracting Party in the territory of which the transferee has a real and effective industrial or commercial establishment: (b) Where the transferee is not a national of a Contracting State or of a State member of a Contracting Organization and the address given in item 3(b) is not in the territory of any of the Contracting Parties mentioned in paragraph (a)(iii) or (iv) of the present item, indicate in the space provided below: (i) (ii) MM5(E) – I.08 the address of the transferee in the territory of the Contracting Party mentioned in paragraph (a)(iii) of the present item; or, the address of the transferee’s industrial or commercial establishment in the territory of the Contracting Party mentioned in paragraph (a)(iv) of the present item. American LegalNet, Inc. www.FormsWorkflow.com Page 2 5 APPOINTMENT OF A REPRESENTATIVE BY THE NEW OWNER1 Name: Address: Telephone: Fax: E-mail address: Signature of the new owner appointing the above representative (compulsory) 1 6 This item should be used where the new owner (transferee) wishes to appoint a representative. Note that, if the person recorded as the representative of the transferor is to be recorded as the representative of the transferee, such appointment should be made by completing this item. Alternatively, the new owner may appoint a representative by means of a power of attorney annexed to the present request. SCOPE OF THE CHANGE IN OWNERSHIP (check either (a) or (b)) TOTAL CHANGE IN OWNERSHIP (the change in ownership is to be recorded for all the Contracting Parties designated in the international registration(s) indicated in item 1, and for all the goods and services covered by such international registration(s)); (a) PARTIAL CHANGE IN OWNERSHIP (read note No. 2 on the cover page before checking this box) (b) (i) the change in ownership is to be recorded for the designated Contracting Parties indicated below (if no Contracting Party is indicated, it will be understood that the change in ownership is to be recorded in respect of all the designated Contracting Parties); and/or, (ii) the change in ownership is to be recorded for the goods and services indicated below (grouped in the appropriate classes); if no goods and services are indicated, it will be understood that the change in ownership is to be recorded in respect of all goods and services. If the space provided is not sufficient, check this box and use a continuation sheet 7 MISCELLANEOUS INDICATIONS (a) Indications concerning the transferee (as may be required by certain designated Contracting Parties): (i) if the transferee is a natural person, nationality of the transferee: (ii) if the transferee is a legal entity: – legal nature of the legal entity: – State and, where applicable, territorial unit within that State, under the law of which the legal entity is organized: (b) The transferee may choose a preferred language for correspondence: 8 English French SIGNATURE BY THE HOLDER OR HIS REPRESENTATIVE Holder (as recorded in the International Register) Representative of the holder (as recorded in the International Register) Name: Name: Signature: 9 Spanish Signature: OFFICE PRESENTING THE REQUEST (if applicable) Name of the Office: Signature and/or stamp of the Office: MM5(E) – I.08 American LegalNet, Inc. www.FormsWorkflow.com 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)). Account number: Holder of the account: Identity of the party giving the instructions: (b) AMOUNT OF FEES; METHOD OF PAYMENT Amount (177 Swiss francs) x (per international registration mentioned in item 1) Grand total (Swiss francs) 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 Credit Suisse, CH-1211 Geneva 70 Swift/BIC: CRESCHZZ80A Payment made to WIPO postal account IBAN No. CH03 0900 0000 1200 5000 8 Swift/BIC: POFICHBE MM5(E) – I.08 Payment identification dd/mm/yyyy Payment identification dd/mm/yyyy American LegalNet, Inc. www.FormsWorkflow.com CONTINUATION SHEET MM5(E) – I.08 No: .......... of .......... American LegalNet, Inc. www.FormsWorkflow.com