P14-CANCELLATION VARIATION OF VOLUNTARY LICENCE

REPUBLIC OF NAMIBIA

BUSINESS AND INTELLECTUAL PROPERTY

AUTHORITY (BIPA)

INDUSTRIAL PROPERTY ACT, 2012 Form No. P14

CANCELLATION/VARIATION OF VOLUNTARY LICENCE

(Section 51(5) and regulation 54(3))

Patent / Application No. Applicant’s or Agent’s Reference

Full Name(s) of Applicant(s)/ Licensor

Address for Service

The Applicant/Licensor hereby applies for cancellation/variation of the Voluntary Licence recorded

between:

Full Name(s) of Licensor

Address for Service

And,

Full Name(s) of Licensee

Address for Service

Reasons for cancellation/variation

Details of the variation:

Additional Information

The following items accompany this Form:

Evidence of termination or expiry of the Voluntary License Contract

Fees

a statement in duplicate of the facts upon which the applicant relies and evidence in

duplicate

verifying the statement

Other (specify)

Signed this _________________________ day of _______________________________ 20 _____

________________________________

Signature (Applicant/Agent)

_______________________________________________________________________________

For Official Use:

Application Reference No.:

Official Date Stamp