MM16(E)

MADRID PROTOCOL CONCERNING THE

INTERNATIONAL REGISTRATION OF MARKS

SUBSEQUENT DESIGNATION RESULTING FROM CONVERSION

(EUROPEAN UNION)

IMPORTANT

This request must be presented to the International Bureau through the intermediary of the Office of the European Union: the European Union Intellectual Property Office (EUIPO).

This cover page must not be sent to the International Bureau.

Madrid System – Contacts

Madrid Customer Service opening hours:Monday – Friday, 9:00 a.m. to 6:00 p.m. (Geneva time)Telephone: + 41 22 338 86 86

Inquiries / submitting forms: http://www.wipo.int/madrid/en/contact/

Mailing address

Madrid Operations DivisionMadrid RegistryBrands and Designs SectorWorld Intellectual Property Organization (WIPO)34, Chemin des Colombettes1211 Geneva 20Switzerland

MM16(E) – February 2020

MM16(E), page 2

MM16(E) – February 2020

MM16(E)SUBSEQUENT DESIGNATION RESULTING FROM CONVERSION

For use by the holder

This subsequent designation contains the following number of

continuation sheets:

Holder’s reference:

For use by the Office

Office’s reference:

INTERNATIONAL REGISTRATION NUMBER

HOLDER(as recorded in the International Register)

Name:

Address:

E-mail address:

By providing an e-mail address, any further correspondence from the International Bureau related to this international registration will be sent only electronically and, therefore, you will no longer receive any paper correspondence. Likewise, any further correspondence from the International Bureau related to other international applications or international registrations for which the same e-mail address has been, or will be, provided will also 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 registration.

APPOINTMENT OF A (NEW) REPRESENTATIVE(only complete this item if you are appointing a (new) representative)

Name:

Address:

Telephone: Fax:

E-mail address:

By providing an e-mail address, any further correspondence from the International Bureau related to this international registration will be sent only electronically and, therefore, you will no longer receive any paper correspondence. Likewise, any further correspondence from the International Bureau related to other international applications or international registrations for which the same e-mail address has been, or will be, provided will also 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 registration.

SIGNATURE OF THE HOLDER APPOINTING THE ABOVE (NEW) REPRESENTATIVE

MM16(E) – February 2020

1

2

3

MM16(E), page 2

GROUND FOR THE CONVERSION OF THE DESIGNATION OF THE EUROPEAN UNION

The designation of the European Union in the international registration indicated in item 1 (tick the appropriate box):

has been the subject of a final refusalhas not been renewed and the possibility to renew the mark has lapsedhas been the subject of a partial cancellationhas been the subject of an invalidationhas been the subject of a renunciation

DESIGNATED CONTRACTING PARTIES1

AT AustriaBG BulgariaBX Benelux2

CY CyprusCZ Czech RepublicDE GermanyDK Denmark

EE EstoniaES SpainFI FinlandFR FranceGB United Kingdom3

GR Greece

HR CroatiaHU HungaryIE Ireland3

IT ItalyLT LithuaniaLV Latvia

PL PolandPT PortugalRO RomaniaSE SwedenSI SloveniaSK Slovakia

1 The designation of the European Union covers its Member States (Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, The Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden) and, during a transition period, the United Kingdom (for further information, see Information Notice No. 2/2020.

2 The designation of Benelux covers the following States: Belgium, Luxembourg and the Netherlands.3 By designating Ireland and/or the United Kingdom, the holder 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 the present subsequent designation.

MM16(E) – February 2020

4

5

MM16(E), page 3

GOODS AND SERVICES (check only one box)

(a) the subsequent designation is made, in respect of all the Contracting Parties designated in item 5, for all the goods and services covered by the designation of the European Union; or

(b) the subsequent designation concerns all the Contracting Parties designated in item 5 but only some of the goods and services covered by the designation of the European Union. The goods and services (which must be grouped in the appropriate class(es)) concerned are listed in the continuation sheet; or

(c) the subsequent designation is made, in respect of some of the Contracting Parties designated in item 5, for only part of the goods and services covered by the designation of the European Union; those Contracting Parties and the goods and services concerned (which must be grouped in the appropriate class(es)) are indicated below. In respect of the other Contracting Parties designated in item 5, the subsequent designation concerns all the goods and services covered by the designation of the European Union.

You can find indications that are pre-accepted by the International Bureau in the Madrid Goods & Services Manager (MGS) at www.wipo.int/mgs/.

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

SIGNATURE BY THE OFFICE OF THE EUROPEAN UNION (EUIPO)

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:

Name and e-mail address of the contact person in the Office:

MM16(E) – February 2020

6

7

MM16(E), page 4

MM16(E) – February 2020

MM16(E), page 5FEE 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 (300 Swiss francs)

Complementary fees:

Number of designations for which complementary fee is applicable

x

Complementary fee

100 Swiss francs

Total amount of thecomplementary fees

= =>

Individual fees (Swiss francs):

Designated Contracting Parties

Individual fee Designated Contracting Parties Individual fee

Total individual fees =>

GRAND TOTAL (Swiss francs)

(c) METHOD OF PAYMENT

Identity of the party effecting the payment:

Payment received and acknowledged by WIPOWIPO receipt number

Payment made to WIPO bank accountIBAN No. CH51 0483 5048 7080 8100 0Crédit Suisse, CH-1211 Geneva 70Swift/BIC: CRESCHZZ80A

Payment identification dd/mm/yyyy

Payment made to WIPO postal account (within Europe only)IBAN No. CH03 0900 0000 1200 5000 8Swift/BIC: POFICHBE

Payment identification dd/mm/yyyy

MM16(E) – February 2020

CONTINUATION SHEET No: .......... of ..........

MM16(E) – February 2020

MM16(E), page 2

MM16(E) – October 2019