Indications required for OHIM: Applicant s/representative s reference number: a) Name:...

Transcription

1 Office for Harmonization in the Internal Market (OHIM) Reserved for OHIM: Date of receipt Number of pages Application for International Registration governed exclusively by the Madrid Protocol OHIM-Form V. 4/04 EM 2 EN (corresp. to WIPO- Form MM2 E) 0 Indications required for OHIM: Applicant s/representative s reference number: 0.4 Payment of the OHIM fee (300 Euro) A current account will be debited only with the OHIM fee; WIPO fees must be paid directly to WIPO current account held at the OHIM paid by bank transfer on OHIM account 0.5 Number of pages, including annexes: Banco Bilbao Vizcaya Argentaria La Caixa 1 2 Office of origin: OHIM Applicant a) Name: ID number attributed by OHIM:... b) Address: c) Address for correspondence: d) Telephone:... e) Preferred language for correspondence with WIPO: English French Spanish Fax.:... f) Other indications (as may be required by certain designated Contracting Parties): i) If the applicant is a natural person, nationality:. ii) If the applicant is a legal entity: - Legal nature of the entity: - State and, where applicable, territorial unit within that State, under the law of which the legal entity is organized:.. 3 Entitlement to file: a) The applicant is a national of a Member State of the European Community, namely:...

2 b) The applicant has a i) domicile ii) real and effective industrial or commercial establishment in a Member State of the EC Address (if different from the address given under item 2 (b)):.. 4 a Representative before WIPO: Name: Address:. Telephone:... Fax: b Representative before OHIM: already appointed in basic application / registration new appointment: Name: Address ID number before OHIM: 5 Basic application or basic registration: The international application is based on: a basic application Basic application number: a basic registration: Basic registration number: a basic registration as soon as the CTM application is registered (Article 141 (2) CTMR): Number of CTM application: Filing date of basic application: (DD/MM/YYYY) Registration date of basic registration: (DD/MM/YYYY) (Registration date: will be added by OHIM) 6 Priority claimed: The applicant claims the priority of the earlier filing mentioned below: Office of earlier filing:. Number of earlier filing (if available). Date of earlier filing (DD/MM/YYYY) If the earlier filing does not relate to all the goods and services indicated in item 10 of this form, specify the goods and service to which it does relate: 7 The mark a) Reproduction of the mark: Same as in basic application / registration Only if word mark c) The applicant declares that he wishes the mark to be considered as a mark in standard characters d) The mark consists of a colour or a combination of colours as such

3 8 Colour(s) claimed: a) The applicant claims the following colour(s) as a distinctive feature of the mark:.. b) Indication, for each colour, of the principal parts of the mark that are in colour (as may be required by certain designated Contracting Parties): 9 Miscellaneous indications concerning the mark a) Transliteration:. b) Translation of the mark into: English French Spanish. c) The mark cannot be translated d) Three-dimensional mark Sound mark Collective mark e) The applicant wishes to include the same description as contained in the basic application / registration: Yes f) Verbal elements of the mark:. g) Disclaimer for the following elements of the mark:.. 10 a) Goods and services for which international registration is sought Registration is sought for the SAME goods and services contained in the basic application / registration Registration is sought only for the FOLLOWING goods and services contained in the basic application / registration Class Goods and services see on continuation sheet b) The applicant wishes to LIMIT the list of goods and services for the following Contracting Party/ies: Contracting Party Classes or goods and services: see on continuation sheet

4 11 Designated Contracting Parties: AG Antigua and Barbuda AL Albania AM Armenia GB United Kingdom * GE Georgia GR Greece MN Mongolia MZ Mozambique NA Namibia AN Netherlands Antilles HR Croatia NO Norway AT Austria HU Hungary PL Poland AU Australia IE Ireland * PT Portugal BG Bulgaria IR Iran (Islamic Republic of) RO Romania BH Bahrain IS Iceland RU Russian Federation BT Bhutan IT Italy SE Sweden BX Benelux JP Japan SG Singapore * BY Belarus KE Kenya SI Slovenia CH Switzerland CN China CU Cuba CY Cyprus CZ Czech Republic DE Germany DK Denmark EE Estonia ES Spain FI Finland FR France KG Kyrgyzstan KP Democratic People s Republic of Korea KR Republic of Korea LI LS Liechtenstein Lesotho LT Lithuania LV Latvia MA Morocco MC Monaco MD Republic of Moldova MK The former Yugoslav Republic of Macedonia SK Slovakia SL Sierra Leone SY Syrian Arab Republic SZ Swaziland TM Turkmenistan TR Turkey UA Ukraine US United States of America ** VN Vietnam YU Serbia and Montenegro ZM Zambia Only Parties to the Madrid Protocol Others: * By designating Ireland, Singapore or the United Kingdom, the applicant 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 this international application ** If the United States of America is designated, it is compulsory to annex to the present international application the official form (MM18) containing the declaration of intention to use the mark required by this Contracting Party. 12 optional Signature by the applicant or his representative: Date (DD/MM/YYYY):....

5 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: Account number: Identity of the party giving the instructions: (b) AMOUNT OF FEES; METHOD OF PAYMENT Basic fee (653 Swiss francs if the reproduction of the mark is in black and white only; 903 Swiss francs if there is a reproduction in color) Complementary and supplementary fees: Number of designations for which complementary fee is applicable Complementary fee Total amount of the complementary fees x 73 Swiss francs = Number of classes of goods and services beyond three x Supplementary fee 73 Swiss francs Total amount of the supplementary fees = Individual fees (Swiss francs): Designated Contracting Individual fee Designated Contracting Individual fee Parties Parties Total individual fees Grand total (Swiss francs) Identity of the party effecting the payment: Payment received and acknowledged by WIPO Payment made by banker s cheque (attached) Payment made by banker s cheque (sent separately) Payment made to WIPO bank account No. CH Credit Suisse, CH-1211 Geneva 70 Swift: CRESCH ZZ12A Payment made to WIPO postal cheque account N o , Geneva WIPO receipt number Cheque identification Cheque identification Payment identification Payment identification

6 CONTINUATION SHEET No :... of...