MM22 (E) – REQUEST FOR THE DIVISION OF AN INTERNATIONAL
REGISTRATION
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1. In accordance with Rule 27bis(1)(d) of the Regulations under the Protocol Relating to the Madrid Agreement Concerning the International Registration of Marks, the Office presenting the request, may check this box and include a statement sent in accordance with either Rule 18bis or 18ter for the goods and services listed in the request.
2. Where the international registration is jointly owned indicate the names of each joint holder as recorded in the international registration here.| For use by the holder: | | | Number of continuation sheets: | | | | Statement attached in accordance with Rule 27bis(1)(d)1 (if applicable, check the box). | | | Holder’s reference: | | | | For use by the Office: | | | Office’s reference: | |
1. CONTRACTING PARTY OF THE OFFICE PRESENTING THE REQUEST
Name of the Contracting Party in respect of which the international registration is to be divided. | | |
2. NAME OF THE OFFICE PRESENTING THE REQUEST
Must be the Office of the Contracting Party indicated in item 1. | | |
3. INTERNATIONAL REGISTRATION NUMBER
International registration to be divided in respect of the Contracting Party indicated in item 1. | | |
4. NAME OF THE HOLDER2
As recorded in the International Register. | | |
5. GOODS AND SERVICES FOR WHICH DIVISION IS TO BE RECORDED
List of the goods and services to be set apart in the divisional international registration, grouped in the appropriate classes. | | | | | If the space provided is not sufficient, check the box and use a continuation sheet. |
6. SIGNATURE OF THE HOLDER AND/OR THEIR REPRESENTATIVE
Only to be completed by the holder or the holder’s representative if required by the Office presenting the request. | | | Holder (as recorded in the International Register): | | | By signing this form, I declare that I am entitled to sign it under the applicable law. | | Name: | | | Signature: | | | | Representative of the holder (before the Office presenting the request): | | | By signing this form, I declare that I am entitled to sign it under the applicable law. | | Name: | | | Signature: | |
| 7. SIGNATURE OF THE OFFICE PRESENTING THE REQUEST | | | (a) | 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. | | | | | (b) | E-mail address of the contact person in the Office: | | |
METHOD OF PAYMENT
If you want to debit the amount of the fees from your Current Account at WIPO, tick the box and provide the information under item (a). If you have already transferred those amounts to WIPO’s bank or postal account, provide as much information as possible under item (b), which would allow WIPO to identify and allocate your payment. | | (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) | BANK OR POSTAL TRANSFER | | | Identity of the party effecting the payment: | | | | Payment received and acknowledged by WIPO | | WIPO receipt number | | Payment made to WIPO bank account
IBAN No. CH51 0483 5048 7080 8100 0
Crédit Suisse, CH-1211 Geneva 70
Swift/BIC: CRESCHZZ80A | | Payment identification | dd/mm/yyyy | | | Payment made to WIPO postal account
(within Europeonly)
IBAN No. CH03 0900 0000 1200 5000 8
Swift/BIC: POFICHBE | | Payment identification | dd/mm/yyyy | | |
| FEE CALCULATION SHEET | | AMOUNT OF FEES | | | The fee is 177 Swiss francs. | TOTAL
(Swissfrancs) | = | 177 | |
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