Application Form

Instruction: Fill out the form from the point of view of the IPO Philippines. Select only the appropriate type of application that applies to you
(i.e. Client or Agent, Agent applicants must indicate their Agent *Code, Alternate email will receive a copy of contents sent to primary *Email)

Applicant Information
YES NO
Business/Company? If yes, name?
YES NO
Individual Sole Proprietor? If yes, name?

Type of Representative
Are you an Employee/Other YES NO
Representative of Applicant? If yes, name?
YES NO
Are you an IP Attorney/Agent? If you answered YES, indicate what Type of Legal Practitioner below
YES NO
Professional Practitioner? If yes?
Type of legal Practitioner *First name *Surname
YES NO
Association? If yes?
Type of legal Practitioner *Name of Law/Professional Firm *Agent Code Issued

Address Information
Address:
*Street Address Apartment/Unit #

*City Province *ZIP Code

*Phone: *Fax: IPO Mailbox:
*Email: Alternate Email:

Data Privacy Notice

By submitting your application, manually or electronically, you agree to the collection, use, disclosure, and processing of your personal data
for legitimate purposes and in accordance with IPOPHL mandate.

Disclaimer and Signature

I certify under pain of perjury that all information I have indicated herein are true and correct to the best of my knowledge and belief, and that
my signature appearing herein is genuine and authentic. I likewise understand that the processing of this application is subject to pertinent
provisions of the implementing rules and regulations of the IPO Philippines.

*Signature: Date:

FOR IPOPHL USE ONLY

Processor
*Processed by: Date:
*Signature: Position:
Remarks:
Fields marked with * are mandatory