P16-APPLICATION FOR COMPULSORY LICENCE INTERDEPENDENCE OF PATENTS

REPUBLIC OF NAMIBIA

INDUSTRIAL PROPERTY TRIBUNAL

INDUSTRIAL PROPERTY ACT, 2012

Form No. P16

APPLICATION FOR COMPULSORY LICENCE: INTERDEPENDENCE OF PATENTS

(Section 56(1) and regulation 56(1)(a))

In the Matter of:

Patent/Utility Model No. Date of Grant

Applicant

Name Address

Address for Service Nationality

Country of Residence/Place of Business

Telephone No. E-mail Address

Title of the invention

Owner of the invention

Request

The above applicant hereby requests the Tribunal, in respect of the patent/utility model, identified

above, to grant a compulsory licence under Section 56(1)/(2) of the Industrial Property Act 2012, in

accordance with the terms proposed and upon the grounds set out below.

Proposed Terms

Amount and conditions of payment of remuneration:

Conditions of exploitation of invention:

Others:

Facts Justifying Grant of Licence

Additional Information

The following items accompany this Form:

Evidence that the owner of the patent or utility model has received a request from the applicant

to obtain a licence but that the applicant has been unable to obtain such a licence on reasonable

terms and within a reasonable time.

Plan according to which the applicant intends to work the invention, including evidence that

applicant has the ability to do so in Namibia.

Other (Specify)

Signed this _________________________ day of _______________________________ 20 _____

____________________________

Signature (Applicant/Agent)