P20-APPLICATION OFFERING TO SURRENDER PATENT UTILITY MODEL

REPUBLIC OF NAMIBIA

BUSINESS AND INTELLECTUAL PROPERTY

AUTHORITY (BIPA)

INDUSTRIAL PROPERTY ACT, 2012 Form No. P20

APPLICATION OFFERING TO SURRENDER PATENT/UTILITY MODEL

(Section 64(1) and regulation 61(1))

Patent/Utility Model No. Filing Date

Full Name(s) of Patentee(s) / Utility Model Owner(s)

Full Address(es) of Patentee(s) / Utility Model Owner(s)

Title of Invention

I/We ___________________________________________________________________________

_______________________________________________________________________________

hereby Declare that --

1. I/We am/are the Patentee(s)/Utility Model Owner(s) mentioned above;

2. I/We hereby offer to surrender the above-mentioned patent/utility model;

3. No action for infringement or proceedings for revocation of the patent/utility model are

pending; and

4. My/our reasons for making this offer are as follows: ________________________________

__________________________________________________________________________.

Address for Service

Signed this _________________________ day of _______________________________ 20 _____

________________________________

Signature (Owner/Agent)

_______________________________________________________________________________

For Official Use:

Official Date Stamp