MM9(E),page

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MM9(E)–March2015

MM9(E)–March2015

MM9(E)

MADRIDAGREEMENTANDPROTOCOLCONCERNINGTHE

INTERNATIONALREGISTRATIONOFMARKS

REQUESTFORTHERECORDINGOFA

CHANGEINNAMEAND/ORADDRESSOFTHEHOLDER

(Rule25oftheCommonRegulations)

IMPORTANT

1. ThisrequestmaybepresentedtotheInternationalBureaudirectlybytheholderorthroughtheOfficeoftheContractingPartyoftheholder.

2. Thisformistobeusedonlytorequesttherecordingofachangeinthenameand/oraddressand/orcorrespondenceaddressoftherecordedholder.TheformtobeusedforrequestingtherecordingofachangeintheownershipoftheinternationalregistrationisformMM5.

WorldIntellectualPropertyOrganization

34,chemindesColombettes

1211Geneva20,Switzerland

Tel.(MadridCustomerService):+41(0)223388686

Fax(MadridRegistry):+41(0)227401429

e-mail:

intreg.mail@

–Internet:

MM9(E)

REQUESTFORTHERECORDINGOFACHANGE

INNAMEAND/ORADDRESSOFTHEHOLDER

Forusebytheholder

Thisrequestcontainsthefollowingnumberofcontinuationsheets:

Holder’sreference:

ForusebytheOffice

Office’sreference:

INTERNATIONALREGISTRATIONNUMBER(S)

(thisformmaybeusedforseveralinternationalregistrationsofthesameholder)

1

1

1

1

1

NAMEOFTHEHOLDER

(asrecordedintheInternationalRegister)

2

3

CHANGEINNAMEAND/ORADDRESSOFTHEHOLDER

(indicatethechange(s)bytickingtheappropriatebox(es))

FORMCHECKBOX

Newname:

FORMCHECKBOX

Newaddress:

Newtelephone: Newfax:

Newe-mailaddress:

Byprovidingane-mailaddress,anyfurthercorrespondencefromtheInternationalBureaurelatedtothis/theseinternationalregistration(s)willbesentonlyelectronicallyand,therefore,youwillnolongerreceiveanypapercorrespondence.Likewise,anyfurthercorrespondencefromtheInternationalBureaurelatedtootherinternationalapplicationsorinternationalregistrationsforwhichthesameemailaddresshasbeen,orwillbe,providedwillalsobesentonlyelectronically.

Pleasenotethat,forthepurposeofelectroniccommunication,therecanbeonlyonee-mailaddressrecordedpereachinternationalregistration.

4

ADDRESSFORCORRESPONDENCE

(Indicatetheaddressforcorrespondence,ifany,andifdifferentfromtheaddressoftheholderindicatedinitem3;ifthisitemisnotcompleted,theaddressforcorrespondencealreadyrecordedintheInternationalRegisterwillbeautomaticallydisregardedbytheInternationalBureau)

Addressforcorrespondence:

APPOINTMENTOFA(NEW)REPRESENTATIVE

(onlycompletethisitemifyouareappointinga(new)representative)

Name:

Address:

Telephone: Fax:

E-mailaddress:

Byprovidingane-mailaddress,anyfurthercorrespondencefromtheInternationalBureaurelatedtothis/theseinternationalregistration(s)willbesentonlyelectronicallyand,therefore,youwillnolongerreceiveanypapercorrespondence.Likewise,anyfurthercorrespondencefromtheInternationalBureaurelatedtootherinternationalapplicationsorinternationalregistrationsforwhichthesameemailaddresshasbeen,orwillbe,providedwillalsobesentonlyelectronically.

Pleasenotethat,forthepurposeofelectroniccommunication,therecanbeonlyonee-mailaddressrecordedpereachinternationalregistration.

SIGNATUREOFTHEHOLDERAPPOINTINGTHEABOVE(NEW)REPRESENTATIVE

5

6

SIGNATUREBYTHEHOLDERAND/ORHISREPRESENTATIVE

Holder Representativeoftheholder

(asrecordedintheInternationalRegister) (asrecordedintheInternationalRegisterorhereinappointed)

Name: Name:

Signature: Signature:

OFFICEOFTHECONTRACTINGPARTYOFTHEHOLDERPRESENTINGTHEREQUEST

(wherethisrequestispresentedthroughanOffice)

7

NameoftheOffice:

NameandsignatureoftheofficialsigningonbehalfoftheOffice:

Nameande-mailaddressofthecontactpersonintheOffice:

FEECALCULATIONSHEET

(a) INSTRUCTIONSTODEBITFROMACURRENTACCOUNT

FORMCHECKBOX

TheInternationalBureauisherebyinstructedtodebittherequiredamountoffeesfromacurrentaccountopenedwiththeInternationalBureau(ifthisboxischecked,itisnotnecessarytocomplete(b)).

Holderoftheaccount: Accountnumber:

Identityofthepartygivingtheinstructions:

(b) AMOUNTOFFEES

(Thefeeis150Swissfrancs,irrespectiveofthenumberofinternationalregistrationslistedinitem

1.No

feeispayable,however,wherethechangeconcernsonlythetelephoneand/ortelefacsimilenumber)

Amount

(c) METHODOFPAYMENT

Identityofthepartyeffectingthepayment:

PaymentreceivedandacknowledgedbyWIPO

FORMCHECKBOX

WIPOreceiptnumber

PaymentmadetoWIPObankaccount

IBANNo.CH5104835048708081000

CréditSuisse,CH-1211Geneva70

Swift/BIC:CRESCHZZ80A