MM16(E) MADRID AGREEMENT AND PROTOCOL CONCERNING THE INTERNATIONAL REGISTRATION OF MARKS SUBSEQUENT DESIGNATION RESULTING FROM CONVERSION (EUROPEAN UNION) IMPORTANT This request must be presented to the International Bureau through the intermediary of the Office of the European Union: the European Union Intellectual Property Office (EUIPO). 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 MM16(E) � October 2016 American LegalNet, Inc. www.FormsWorkFlow.com MM16(E) SUBSEQUENT DESIGNATION RESULTING FROM CONVERSION For use by the holder This subsequent designation contains the following number of continuation sheets: Holder's reference: Office's reference: For use by the Office 1 2 INTERNATIONAL REGISTRATION NUMBER HOLDER (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 international registration 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. 3 APPOINTMENT OF A (NEW) REPRESENTATIVE (only complete this item if you are appointing a (new) representative) Name: Address: Telephone: E-mail address: Fax: By providing an e-mail address, any further correspondence from the International Bureau related to this international registration 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 HOLDER APPOINTING THE ABOVE (NEW) REPRESENTATIVE 4 GROUND FOR THE CONVERSION OF THE DESIGNATION OF THE EUROPEAN UNION The designation of the European Union in the international registration indicated in item 1 (tick the appropriate box): has been the subject of a final refusal has not been renewed and the possibility to renew the mark has lapsed has been the subject of a partial cancellation has been the subject of an invalidation has been the subject of a renunciation MM16(E) � October 2016 American LegalNet, Inc. www.FormsWorkFlow.com MM16(E), page 2 5 DESIGNATED CONTRACTING PARTIES AT BG BX CY CZ DE DK Austria Bulgaria Benelux Cyprus Czechia Germany Denmark EE ES FI FR GB GR Estonia Spain Finland France United Kingdom1 Greece HR HU IE IT LT LV Croatia Hungary Ireland1 Italy Lithuania Latvia PL PT RO SE SI SK Poland Portugal Romania Sweden Slovenia Slovakia 1 By designating Ireland and/or the United Kingdom, the holder declares that he has the intention that the mark will be used by him or with his consent in that country in connection with the goods and services identified in the present subsequent designation. 6 GOODS AND SERVICES (check only one box) (a) the subsequent designation is made, in respect of all the Contracting Parties designated in item 5, for all the goods and services covered by the designation of the European Union; or the subsequent designation concerns all the Contracting Parties designated in item 5 but only some of the goods and services covered by the designation of the European Union. The goods and services (which must be grouped in the appropriate class(es)) concerned are listed in the continuation sheet; or the subsequent designation is made, in respect of some of the Contracting Parties designated in item 5, for only part of the goods and services covered by the designation of the European Union; those Contracting Parties and the goods and services concerned (which must be grouped in the appropriate class(es)) are indicated below. In respect of the other Contracting Parties designated in item 5, the subsequent designation concerns all the goods and services covered by the designation of the European Union. 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 (b) (c) New" or "Times New Roman", size 12 pt, or above. If the space provided above is not sufficient, check the box and use a continuation sheet MM16(E) � October 2016 American LegalNet, Inc. www.FormsWorkFlow.com MM16(E), page 3 7 SIGNATURE BY THE OFFICE OF THE EUROPEAN UNION (EUIPO) 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: MM16(E) � October 2016 American LegalNet, Inc. www.FormsWorkFlow.com MM16(E), page 4 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) Account number: AMOUNT OF FEES (see Fee Calculator: www.wipo.int/madrid/en/fees/calculator.jsp) Basic fee (300 Swiss francs) Complementary fees: Number of designations for which complementary fee is applicable x Complementary fee 100 Swiss francs = Total amount of the complementary fees => Individual fees (Swiss francs): Designated Contracting Parties Individual fee Designated Contracting Parties Individual fee Total individual fees GRAND TOTAL (Swiss francs) (c) METHOD OF PAYMENT =>