P13-RECORDAL OF VOLUNTARY LICENCE

REPUBLIC OF NAMIBIA

BUSINESS AND INTELLECTUAL PROPERTY

AUTHORITY (BIPA)

INDUSTRIAL PROPERTY ACT, 2012 Form No. P13

RECORDAL OF VOLUNTARY LICENCE

(Section 51(2) and regulation 54(1)(b))

For Official Use

Received on:

_______________________________________________________________________________

In the Matter of:

Patent Application / Registration No.

Title of Invention:

Applicant(s)/Owner(s)/ Licensor

Name

Address

Telephone No. E-mail Address

Request

The Registrar is hereby requested to record the voluntary licence of the above-identified patent(s)

with effect from the _______ day of _____________________ 20 _____

Licensee

Name

Address

Telephone No. E-mail Address

Address for Service:

Nationality: Residence or principle place of business:

Additional Information

The following items accompany this Form:

Voluntary Licence Contract

Fees

Other (specify)

Signed this _________________________ day of _______________________________ 20 _____

________________________________

Signature (New Applicant/New Owner)

________________________________

Signature (Applicant/Owner)