Office for Harmonization in the Internal Market (OHIM) Reserved for OHIM: Date of receipt Number of pages Application for International Registration governed exclusively by the Madrid Protocol OHIM-Form V. 4/04 EM 2 EN (corresp. to WIPO- Form MM2 E) 0 Indications required for OHIM: Applicant s/representative s reference number: 0.4 Payment of the OHIM fee (300 Euro) A current current account held at the OHIM account will be debited only with the OHIM paid by bank transfer on OHIM account fee; WIPO fees must be paid directly to WIPO 0.5 Number of pages, including annexes: Banco Bilbao Vizcaya Argentaria La Caixa 1 2 Office of origin: OHIM Applicant a) Name:....... ID number attributed by OHIM:... b) Address:............ c) Address for correspondence:...... d) Telephone:... E-mail: Fax.:... Please check this box if you wish to receive electronic communication. By checking this box: (i) any further correspondence from the International Bureau related to this international application and its resulting international registration will be sent only electronically; likewise, (ii) any further correspondence from the International Bureau related to other international applications or international registrations for which the same e-mail address has been provided will be sent only electronically. Please note that, for the purpose of electronic communication, there can be only one e-mail address recorded per each international application. e) Preferred language for correspondence with WIPO: English French Spanish f) 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:.. 3 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)):.. 4 a Representative before WIPO: Name: Address:. Telephone:... Fax:... E-Mail:.. Please check this box if you wish to receive electronic communication. By checking this box: (i) any further correspondence from the International Bureau related to this international application and its resulting international registration will be sent only electronically; likewise, (ii) any further correspondence from the International Bureau related to other international applications or international registrations for which the same e-mail address has been provided will be sent only electronically. Please note that, for the purpose of electronic communication, there can be only one e-mail address recorded per each international application 4 b Representative before OHIM: already appointed in basic application / registration new appointment: Name: Address ID number before OHIM: 5 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)
6 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: 7 The mark a) Reproduction of the mark: Same as in basic application / registration Only if word mark c) The applicant declares that he wishes the mark to be considered as a mark in standard characters d) The mark consists of a colour or a combination of colours as such 8 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): 9 Miscellaneous indications concerning the mark a) Transliteration:. b) Translation of the mark into: English French Spanish. c) The mark cannot be translated 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) Verbal elements of the mark:. g) Disclaimer for the following elements of the mark:..
10 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: Contracting Party Classes or goods and services: see on continuation sheet 11 Designated Contracting Parties: AG Antigua and Barbuda AL Albania GH Ghana GR Greece NO Norway NZ New Zealand AM Armenia HR Croatia OM Oman AT Austria AU Australia AZ Azerbaijan BA Bosnia and Herzegovina BG Bulgaria BH Bahrain BQ Bonaire, Saint Eustatius and Saba BT Bhutan BW Botswana BX Benelux BY Belarus CH Switzerland CN China CO Colombia CU Cuba CW Curaçao CY Cyprus CZ Czech Republic DE Germany DK Denmark EE Estonia EG Egypt ES Spain FI Finland FR France HU Hungary IE Ireland * IL Israel IN Republic of India IR Iran (Islamic Republic of) IS Iceland IT Italy JP Japan KE Kenya KG Kyrgyzstan KP Democratic People s Republic of Korea KR Republic of Korea KZ Kazakhstan LI Liechtenstein LR Republic of Liberia LS Lesotho LT Lithuania LV Latvia MA Morocco MC Monaco MD Republic of Moldova ME Montenegro MG Madagascar MK The former Yugoslav Republic of Macedonia PH Philippines PL Poland PT Portugal RO Romania RS Serbia RU Russian Federation RW Rwanda SD Sudan SE Sweden SG Singapore * SI Slovenia SK Slovakia SL Sierra Leone SM San Marino ST Democratic Republic of Sao Tome and Principe SY Syrian Arab Republic SZ Swaziland SX St. Martin TJ Tajikistan TM Turkmenistan TN Republic of Tunisia TR Turkey UA Ukraine US United States of America **
GB United Kingdom * GE Georgia MN Mongolia MZ Mozambique MX Mexico NA Namibia UZ Uzbekistan VN Vietnam ZM Zambia 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. 12 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: Account number: 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 Number of classes of goods and services beyond three x x Complementary fee 100 Swiss francs Supplementary fee 100 Swiss francs Total amount of the complementary fees = => Total amount of the supplementary fees = => Individual fees (Swiss francs): Designated Contracting Parties Individual fee Designated Contracting Parties Individual fee (c) METHOD OF PAYMENT Total individual fees => GRAND TOTAL (Swiss francs) Identity of the party effecting the payment: 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 WIPO receipt number Payment identification Payment identification dd/mm/yyyy dd/mm/yyyy
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