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Office for Harmonization in the Internal Market

(OHIM)Reserved forOHIM:

Date of receipt Number of pages

Application for International Registration

governed exclusively by the Madrid Protocol

OHIM-Form V. 4/04EM 2 EN(corresp. toWIPO-Form MM2E)

0 Indications required for OHIM: Applicants/representatives reference number:

0.4 Payment of the OHIM fee (300 Euro)A currentaccount will bedebited only

current account held at the OHIM

with the OHIMfee; WIPO feesmust be paid

directly toWIPO

paid by bank transfer on OHIM account Banco Bilbao Vizcaya Argentaria

La Caixa

0.5 Number of pages, including annexes:

1 Office of origin: OHIM

2 Applicant

a) Name: ..................................................................

...................................................................

ID number attributed by OHIM:

.......................................................

b) Address: .............................................................................................. ..............................

............... .............................................................................................................................

c) Address for correspondence: ..............................................................................................

.............................................................................................................................................

d) Telephone: ..................

E-mail:

Fax.: .................................................

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 entityis 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

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ii) real and effective industrial or commercial establishmentin 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: ..

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 applicationBasic application number: Filing date of basic application:

(DD/MM/YYYY)

a basic registration:Basic registration number: Registration date of basic registration:

(DD/MM/YYYY)

a basic registration as soon as the CTMapplication is registered (Article 146 (2) CTMR):

Number of CTM application: (Registration date: will be added byOHIM)

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 initem 10 of this form, specify the goods and service to which it does relate:

7 The marka) Reproduction of the mark:

Same as in basic application / registrationOnly if wordmark 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:

..

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b) Indication, for each colour, of the principal parts of the mark that are in colour (as may berequired 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 basicapplication / registration

Registration is sought only for the FOLLOWING goods and services contained in the basic

application / registrationClass Goods and services see on continuation sheet

b) The applicant wishes to LIMIT the list of goods and services for the following ContractingParty/ies:

Contracting Party Classes or goods and services: see on continuation sheet

11 Designated Contracting Parties:

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AG Antigua and Barbuda

AL Albania

AM Armenia

AT Austria

AU Australia

AZ AzerbaijanBA Bosnia and Herzegovina

BG Bulgaria

BH Bahrain

BQ Bonaire, Saint Eustatiusand Saba

BT Bhutan

BW Botswana

BX Benelux

BY Belarus

CH Switzerland

CN China

CU Cuba

CW Curaao

CY Cyprus

CZ Czech Republic

DE Germany

DK Denmark

EE Estonia

EG Egypt

ES Spain

FI Finland

FR France

GB United Kingdom*

GE Georgia

GH Ghana

GR Greece

HR Croatia

HU Hungary

IE Ireland*

IL Israel

IR Iran (Islamic Republic of)

IS Iceland

IT Italy

JP Japan

KE Kenya

KG Kyrgyzstan

KP Democratic Peoples

Republic of Korea

KR Republic of KoreaKZ 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

MN Mongolia

MZ Mozambique

NA Namibia

NO Norway

OM Oman

PL Poland

PT Portugal

RO Romania

RS Serbia

RU Russian Federation

SD Sudan

SE Sweden

SG Singapore*

SI Slovenia

SK Slovakia

SL Sierra Leone

SM San MarinoST Democratic Republic of

Sao Tome and Principe

SY Syrian Arab Republic

SZ Swaziland

SX St. Martin

TJ Tajikistan

TM Turkmenistan

TR Turkey

UA Ukraine

US United States of

America**

UZ Uzbekistan

VN Vietnam

ZM Zambia

Only Partiesto the MadridProtocol

Others:

* By designating Ireland, Singapore or the United Kingdom, the applicant declares that he hasthe 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 presentinternational application the official form (MM18) containing the declaration of intention touse the mark required by this Contracting Party.

12

optional

Signature by the applicant or his representative:

..

Date (DD/MM/YYYY):

..

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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 and903 Swiss francs if there is a reproduction in color. (For international applications filed by applicantswhose country of origin is a Least Developed Country, in accordance with the list established by theUnited Nations (www.wipo.int/ldcs/en/country) , 65 Swiss francs if the reproduction is in black andwhite only and 90 Swiss francs if there is a reproduction in color.)

Complementary and supplementary fees:

Number of designationsfor which complementary

fee is applicable

x

Complementary fee

100 Swiss francs

Total amount of the

complementary fees

= =>

Number of classes ofgoods and services beyondthree

x

Supplementary fee

100 Swiss francs

Total amount of thesupplementary fees

= =>

Individual fees (Swiss francs):

Designated ContractingParties

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 WIPO

WIPO receipt number

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

Payment identification

dd/mm/yyyy

Payment made to WIPO postal accountIBAN No. CH03 0900 0000 1200 5000 8Swift/BIC: POFICHBE

Payment identification

dd/mm/yyyy

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