MM12(E)
MADRID AGREEMENT AND PROTOCOL CONCERNING THE
INTERNATIONAL REGISTRATION OF MARKS
APPOINTMENT OF A REPRESENTATIVE
IMPORTANT
1. The use of this form is not compulsory. It is made available for the convenience of holders of
international registrations.
2. This form may relate to one or more international registrations of the same holder.
World Intellectual Property Organization
34, chemin des Colombettes
1211 Geneva 20, Switzerland
Tel. (Switchboard): +41 (0)22 338 9111
Fax (Madrid Registry): +41 (0)22 740 1429
e-mail: intreg.mail@wipo.int – Internet: http://www.wipo.int
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MM12(E)
APPOINTMENT OF A REPRESENTATIVE
For use by the applicant/holder For use by the holder/Office
This request contains the following number of continuation sheets: Holder’s reference:
Office’s reference:
1 NAME OF THE HOLDER
(as recorded in the International Register)
2
1 INTERNATIONAL REGISTRATION NUMBER(S)
(this form may be used for several international registrations of the same holder)
Indicate below the international registration number(s) concerned by the appointment of the representative:
3 REPRESENTATIVE
Name:
Address:
Telephone: Fax:
E-mail address:
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 HOLDER
(as recorded in the International Register)
Name:
Signature:
5 OFFICE PRESENTING THE REQUEST
(where applicable)
Name of the Office
Signature and/or stamp of the Office
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CONTINUATION SHEET No: .......... of ..........
MM12(E) – January 2013 American LegalNet, Inc.
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