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Office for Harmonization in the Internal Market (OHIM)

Reserved for OHIM: Date of receipt Number of pages OHIM-Form V. 4/04 EM 2 EN (corresp. to WIPO-Form MM2 E)

Application for International Registration governed exclusively by the Madrid Protocol 0 0.4
Indications required for OHIM:

Applicants/representatives reference number:

Payment of the OHIM fee (300 Euro) current account held at the OHIM paid by bank transfer on OHIM account Banco Bilbao Vizcaya Argentaria La Caixa

A current account will be debited only with the OHIM fee; WIPO fees must be paid directly to WIPO

0.5 1 2

Number of pages, including annexes:

Office of origin: OHIM Applicant a) b) c) d) e) f) Name: .................................................................. ................................................................... ID number attributed by OHIM: .......................................................

Address: .............................................................................................. .............................. ............... ............................................................................................................................. Address for correspondence: .............................................................................................. ............................................................................................................................................. Telephone: .................. E-mail: Preferred language for correspondence with WIPO: English French Spanish 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: .. Fax.: .................................................

Entitlement to file: a) The applicant is a national of a Member State of the European Community, namely:

.................................................................................

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)): . .

4a

Representative before WIPO: Name: Address: . Telephone: ... Fax: .......... E-Mail: ..

4b

Representative before OHIM: already appointed in basic application / registration new appointment: Name: Address ID number before OHIM:

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 146 (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)

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:

The mark a) Reproduction of the mark:

Only if word mark

c) d)

Same as in basic application / registration The applicant declares that he wishes the mark to be considered as a mark in standard characters The mark consists of a colour or a combination of colours as such

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):

Miscellaneous indications concerning the mark a) b) c) 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) g) Verbal elements of the mark: . Disclaimer for the following elements of the mark: .. Transliteration: . Translation of the mark into: The mark cannot be translated English French Spanish .

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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: Classes or goods and services: see on continuation sheet

Contracting Party

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Designated Contracting Parties:

AG Antigua and Barbuda AL Albania AM Armenia AT Austria AU Australia AZ Azerbaijan BA Bosnia and Herzegovina BG Bulgaria BH Bahrain

GE Georgia GH Ghana GR Greece HR Croatia HU Hungary IE IL IR IS IT JP Ireland * Israel Iran (Islamic Republic of) Iceland Italy Japan

MN Mongolia MZ Mozambique NA Namibia NO Norway OM Oman PL PT Poland Portugal

RO Romania RS Serbia RU Russian Federation SD SE SI SL ST Sudan Sweden Slovenia Sierra Leone Democratic Republic of Sao Tome and Principe Swaziland

BQ Bonaire, Saint Eustatius


and Saba BT Bhutan BW Botswana BX Benelux BY Belarus CH Switzerland CN China CU Cuba

KE Kenya KG Kyrgyzstan KP Democratic Peoples Republic of Korea KR Republic of Korea KZ Kazakhstan LI LS Liechtenstein Lesotho LR Republic of Liberia LT Lithuania LV Latvia MA Morocco MC Monaco MD Republic of Moldova ME Montenegro MG Madagascar
*

SG Singapore * SK Slovakia SM San Marino

CW Curaao
CY Cyprus CZ Czech Republic DE Germany DK Denmark EE ES FI FR Estonia Spain Finland France EG Egypt

SY Syrian Arab Republic SZ

SX St. Martin TJ Tajikistan


TM Turkmenistan TR Turkey UA Ukraine US United States of America** UZ Uzbekistan VN Vietnam ZM Zambia

GB United Kingdom

MK The former Yugoslav Republic of Macedonia

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.

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optional

Signature by the applicant or his representative:

Date (DD/MM/YYYY):

..

..

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) AMOUNT OF FEES (see Fee Calculator: www.wipo.int/madrid/en/fees/calculator.jsp) Basic fee: 653 Swiss francs if the reproduction of the mark is in black and white only and 903 Swiss francs if there is a reproduction in color. (For international applications filed by applicants whose country of origin is a Least Developed Country, in accordance with the list established by the United Nations (www.wipo.int/ldcs/en/country), 65 Swiss francs if the reproduction is in black and white only and 90 Swiss francs if there is a reproduction in color.) Complementary and supplementary fees: Number of designations for which complementary fee is applicable x Number of classes of goods and services beyond three x Individual fees (Swiss francs): Designated Contracting Parties Individual fee Designated Contracting Parties Individual fee Total amount of the complementary fees = => Total amount of the supplementary fees = => Account number:

Complementary fee 100 Swiss francs

Supplementary fee 100 Swiss francs

Total individual fees GRAND TOTAL (Swiss francs)


(c) METHOD OF PAYMENT 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
Payment identification dd/mm/yyyy

Payment identification

dd/mm/yyyy

CONTINUATION SHEET

No : ......... of ..........