MINISTRY OF JUSTICE AND HUMAN RIGHTS R.I.

DIRECTORATE GENERAL OF INTELLECTUAL PROPERTY Created in 2 copies

Patent Application Form

Filled by officers
Date of application :
Number of application :

Hereby I / we 1):
(71) N a m e :
Address 2) :
Citizen :
Phone No :
Email :
taxpayer identification number (if any) :                                                     

apply for a patent/simple patent

[ ]

which is a patent application

International / PCT by the numbers
   

(74) through / not through *) IP Consultant [ ]

Name of Legal Entity 3):
Legal Entity Address 2):

IP Consultant Name:
Address 2):
IP Consultant numbers:
Phone / Fax:
email:

(54) with the title of the invention:

[ ]

This patent application is a fraction / Change [ ]

of a patent application number:
 Filled by officers

(72) The name and address and nationality of the inventor (s): [ ]
[ ]
Name: / address/(email address if any), citizens
Name: / address/(email address if any), citizens
Name: / address/(email address if any), citizens
Name: / address/(email address if any), citizens

(30) The patent application was filed with / not with *) [ ]

priority rights 4)

Country: Date. Receipt of the request a priority number

Herewith I enclose 5):

1 (one) copy:
[ ] power of attorney [ ]
[ ] Letter of transfer of rights to the invention [ ]
[ ] A statement of ownership of the invention by the inventor. [ ]
[ ] Evidence of the appointment of the country of destination (DO / EO) [ ]
[ ] The priority documents and translations [ ]
[ ] International patent application document / PCT [ ]
[ ] Certificates of deposit of microorganisms and translations [ ]
[ ] Other documents (specify): [ ]

and 1 (one) copy of the invention comprises:

[ ] Description page
[ ] Claim(s)
[ ] Abstract
[ ] Drawing (s) (if any)

I / we are proposing, image numbers can be [ ]

accompany the abstract at the time of the publication/announcement on
a patent application (Law No. 13 of 2016)

Thus this patent application I / we submitted

for further processing
 Applicant,

( ) 6)

Information :
1) If more than one person then simply one were included in this form
while others written on an additional attachment.
2) Is the official address / correspondence.
3) If the Patent Consultant appointed to work on a particular legal entity engaged
in the field of patent agent then give the name of the legal entity concerned.
4) If more than the space provided that written on an additional attachment.
5) Put a cross on the type of document you attach.
6) If the patent application is filed by:
- More than one person, any person designated by the group / group
- The right to sign the Patent Consultants is a consulting registered Patent Office.

*) pick up as needed.

Form No. 001/P/KI/2016