[The relevant information must be filled up in colored box against the respective head]

PART A [applicants details]

FEE

(See First Schedule for Appropriate Fee)

Name in full beginning with surname (in capital letters)*

Father's /Husband's Name*

Address of residence*

Address of residence*

(State) (Country)

Principle place of business*

(State) (Country)

Nationality*

Mobile No:*

E-mail address:*

PART B: PURPOSE OF REQUEST [appropriate column required to be ticked and filled accordingly]

a

Application for Registration as Trademark Agent

Date of Place of Birth

Occupation in full

Particulars of qualification for registration as a trade mark agent

Whether at any time removed from the Register of Trade Marks Agents and if so the details thereof

b

Application for continuation/restoration of the name of a person in the Register of Trade Marks Agents

Trade Mark Agent No.

Name:

address

Mobile No :

E-mail address:

i

Period for Continuation: From _____ to _____

ii

Date of expiration of last registration:

Years after which request for restoration and continuation is filed

c

Application for alteration in the Register of Trade Marks Agents

Trade Mark Agent No.:

Name:

Details to be altered in and as

Name:

Address of place of residence

Address of principle place of business

Educational Qualification

Mobile No:

E-mail address:

PART C [details of the person making application/request and details of document is submitted]

Signature

Name

Authority

List of documents attached