Form No. 5, page 1

INTELLECTUAL PROPERTY OFFICE, TRINIDAD AND TOBAGO

PATENTS ACT

APPLICATION TO REGISTER OR TO GIVE NOTICE OF TRANSACTION, ETC.; RECORDING OF CHANGE OF OWNERSHIP

To: The Controller

Intellectual Property Office

For Official Use

Received on:

Applicant’s or Representative’s

File Reference:

I. IN THE MATTER OF

Patent Application No.

Filing Date:

Application for Utility Certificate N/A

Filing Date: N/A

Patent No.: N/A

Date of Grant: N/A

Utility Certificate No.: N/A

Date of Grant: N/A

2. APPLICATION TO REGISTER, OR TO GIVE NOTICE OF

TRANSACTION, ETC.

PERSON(S) MAKING THE APPLICATION:

Name(s):

Address(es):

2. REQUEST FOR RECORDING OF CHANGE IN OWNERSHIP

The Controller is hereby requested to record the change in ownership of the

above-identified * Patent Application No.

The present applicant(s)/ owner ^† is identified below.

The present applicant(s)/ new owner ^† is identified below.

FORMER APPLICANT(S) / OWNER(S)^†:

Name(s):

Address(es):

* Indicate application or title concerned.

^† Delete whichever does not apply

NEW APPLICANT(S) / NEW OWNER(S)*

Name(s):

Addresses(es):

Nationality/nationalities:

Country/countries of residence or principal place(s) of business:

Tel. No.: Telegraphic Address(es): Telex No.: Fax No.:

V. SIGNATURES

……..………………………………(Person(s) making the application^†) ………………………… (Date)

…………………………………… [New Applicant(s)/New Owner(s)^†) …………………………… (Date)

…………………………………… [Former Applicant(s)/Owner(s)^‡] ………………………………

(Date)

* Delete whichever does not apply.

† Type name under signature

‡ Delete whichever does not apply and type name(s) under signature(s).