P04-APPLICATION FOR CONVERSION OF PATENT UTILITY MODEL APPLICATION

REPUBLIC OF NAMIBIA

BUSINESS AND INTELLECTUAL PROPERTY

AUTHORITY (BIPA)

INDUSTRIAL PROPERTY ACT, 2012 Form No. P4

APPLICATION FOR CONVERSION OF PATENT/ UTILITY MODEL APPLICATION

(Sections 33(1) and 90 and regulations 44(1) and 66(1))

For Official Use:

Application No.:

Filing Date:

(Official Date Stamp)

_______________________________________________________________________________

The applicant hereby applies to convert the patent /utility model application whose particulars are

indicated herein to a utility model/patent application in accordance with sections 33(1) and 90 of the

Act.

The full reasons for making the conversion are as follows:

Select One: Patent

Utility Model

Title of Invention:

Applicant’s Personal Details (in case of two or more applicants, provide details on a separate sheet):

Name

Address

Country Region Postcode

Nationality

Country of

Residence or

Principal Place

of Business

Telephone E-mail

Agent: (The following agent has been appointed by the applicant(s) in the power of attorney

accompanying this Form.)

Name

Address

Inventor:

The Inventor is the Applicant

If Inventor is not the Applicant (in case of two or more applicants, provide details on a separate

sheet):

Name

Address

Country Region Postcode

The statement justifying the Applicant’s right must accompany this Form.

Divisional Application:

This Application is a Divisional Application

The benefit of the filing date of the initial application is claimed as the subject matter of the present

application is contained in the initial application identified below.

Initial

Application No.

Initial

Application

Filing Date

Disclosures to be Disregarded for Prior Art Purposes:

Disclosure occurred not more than six months before the filing date or priority date of the present

application:

by reason or in consequence of acts of the applicant or his or her or its

predecessor in title.

by reason or in consequence of an abuse committed by a third party with

regard to the rights of applicant or his or her or its predecessor in title.

Additional information is contained in a statement accompanying this Form.

Priority Declaration:

The priority of (an) earlier application(s) is claimed as follows

Country (if the earlier application is a regional or international application, indicate the office with

which and the countries for which it was filed):

Filing Date Application Number

The certified copy of the earlier application will be furnished as prescribed by Regulation 37(6).

The English translation of the earlier application will be furnished as prescribed by Regulation 37(7).

Supplemental Box:

The priority of more than one earlier application is claimed; the data are indicated in the supplemental

box

A. This application contains the following:

Request sheet(s).

Description sheet(s).

Claim(s) sheet(s).

Abstract sheet(s).

Drawing(s) sheet(s).

B. This form is accompanied by the items ticked below:

Separate signed Declaration and Power of Attorney

Statement justifying the Applicant’s right to a patent or utility model

Statement that certain disclosures be disregarded

English translation of priority application(s) on which priority declaration is based

Application fee

Other document(s) (List below)

Signed this _________________________ day of _______________________________ 20 _____

____________________________

Signature (Applicant/Agent)