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. This request may be presented to the International Bureau directly by the holder (or his recorded representative), through the Office of the Contracting Party of the (recorded) holder or through the Office of the Contracting Party of the new owner (transferee). 2. 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. 3. 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. 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 MM5(E) � September 2016 American LegalNet, Inc. www.FormsWorkFlow.com MM5(E) REQUEST FOR THE RECORDING OF A CHANGE IN OWNERSHIP For the holder (transferor)/new owner (transferee) This request contains the following number of continuation sheets: Office's reference: For the Office Holder/new owner's reference: 1 INTERNATIONAL REGISTRATION NUMBER(S) (several international registrations 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)) 2 NAME OF THE HOLDER (TRANSFEROR) (as recorded in the International Register) 3 NEW OWNER (TRANSFEREE) (a) Name: (b) Address: (c) Address for correspondence: (d) Telephone: E-mail address: 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. MM5(E) � September 2016 American LegalNet, Inc. www.FormsWorkFlow.com MM5(E), page 2 4 ENTITLEMENT OF THE NEW OWNER (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 new owner (transferee) is a national; and/or, (ii) the name of the State member of a Contracting Organization of which the new owner (transferee) is a national; and/or, (iii) the name of the Contracting Party in the territory of which the new owner (transferee) is domiciled; and/or, (iv) the name of the Contracting Party in the territory of which the new owner (transferee) has a real and effective industrial or commercial establishment: (b) Where the new owner (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) the address of the new owner (transferee) in the territory of the Contracting Party mentioned in paragraph (a)(iii) of the present item; or, the address of the new owner's (transferee) industrial or commercial establishment in the territory of the Contracting Party mentioned in paragraph (a)(iv) of the present item. 5 APPOINTMENT OF A REPRESENTATIVE BY THE NEW OWNER (TRANSFEREE)1 Name: Address: Telephone: E-mail address: 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. SIGNATURE OF THE NEW OWNER (TRANSFEREE) APPOINTING THE ABOVE REPRESENTATIVE (compulsory) 1 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 holder (transferor) is to be recorded as the representative of the new owner (transferee), such appointment should be made by completing this item. MM5(E) � September 2016 American LegalNet, Inc. www.FormsWorkFlow.com MM5(E), page 3 6 SCOPE OF THE CHANGE IN OWNERSHIP (check either (a) or (b)) (a) 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)); PARTIAL CHANGE IN OWNERSHIP (read note No. 3 on the cover page before checking this box) (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, (b) (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. You can find indications that are pre-accepted by the International Bureau in the Madrid Goods & Services Manager (MGS) at www.wipo.int/mgs/. Please make consistent use of a semicolon (;) to clearly specify the goods and services indications in your list, e.g.: 09 Scientific, optical and electronic apparatus and instruments; screens for photoengraving; computers. 35 Advertising; compilation of statistics; commercial information agencies. Please use font "Courier New" or "Times New Roma