PARTIAL CHANGE IN OWNERSHIP (read note No. 3 on the cover page before checking this box) 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, 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 xxx.xxxx.xxx/xxx/. 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 Roman”, size 12 pt, or above. If the space provided above is not sufficient, check the box and use a continuation sheet
PARTIAL CHANGE IN OWNERSHIP (read note No. 3 on the cover page before checking this box)
PARTIAL CHANGE IN OWNERSHIP (read note No. 2 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, (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. If the space provided is not sufficient, check this box and use a continuation sheet 7 MISCELLANEOUS INDICATIONS (a) Indications concerning the transferee (as may be required by certain designated Contracting Parties): (i) if the transferee is a natural person, nationality of the transferee: (ii) if the transferee is a legal entity: – legal nature of the legal entity: – State and, where applicable, territorial unit within that State, under the law of which the legal entity is organized: (b) The transferee may choose a preferred language for correspondence: English French Spanish 8 SIGNATURE BY THE HOLDER OR HIS REPRESENTATIVE Holder Representative of the holder (as recorded in the International Register) (as recorded in the International Register) Name: Name: Signature: Signature: 9 OFFICE PRESENTING THE REQUEST (if applicable) Name of the Office: Signature and/or stamp of the Office: 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 Amount (177 Swiss francs) x (per international registration mentioned in item 1) Grand total (Swiss francs) Identity of the party effecting the payment: WIPO receipt number Payment received and acknowledged by WIPO Payment made to WIPO bank account IBAN No. XX00 0000 0000 0000 0000 0 Payment identification dd/mm/yyyy Credit Suisse, CH-1211 Geneva 70 Swift/BIC: XXXXXXXX00X Payment made to WIPO postal account Payment identification dd/mm/yyyy IBAN No. XX00 0000 0000 0000 0000 0 Swift/BIC: XXXXXXXX
