Form 	TM -No 1
		TRADE MARK ACT
 
Authorisation of Agent.
 
For official use only.
 
 
 
1	Appointment
 
 
The undersigned hereby appoints as his representative the person identified 
in item 3 ,below
 
 
________________________________________________________
2.	Name of person making the appointment
 
 
_______________________________________________________
3.	Representative
3. 3.1 Name :
 
 
3.2 Address ( including postal code and country)
 
 
Telephone number (s):		Telefacsimile number (s)
(with the area code )		(with the area code)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
			2.
Form TM -No 1, Page 2
______________________________________
 
 
 
4.	Application (s) and /or registration (s) concerned.
 
This authorisation of agent concerns :
 
4.1	all existing and future applications and /or registrations of the person 
making the appointment, subject to any exception indicated on an additional sheet.
 
 
 
4.2 	the following application(s) and/or registration (s):
 
4.2.1 the application(s) concerning the following mark (s) *
 
 
 
	4.2.2 the application having the following application number (s) as well as 
any registration (s) resulting therefrom:
		
 
	4.2.3 the registration having the following registration number (s)
	4.2.4 If the spaces under 4.2.1 or 4.2.2 or 4.2.3 are not sufficient check this 
		box and provide the information 
		on an additional sheet.	
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
			3.
		Form TM - No. 1, Page 3.
 
 
5. Scope of the Authorisation of Agent
 
1. Check this box if the representative has the right to act as representative for all purposes , 
including, where the person making the appointment is an applicant or a holder, the following 
purposes:
1. withdrawal of the application (s)
 
2. surrender of the registration (s)
 
 
5.2	Check this box if the representative does not have the right to act as representative for all purposes and 
indicate here or on an additional sheet purposes excluded from the powers of the representative:
 
_________________________________________________________
5. Signature 
 
 
6.1 Name of natural person who signs:
 
 
6.2 Date of signature:
 
 
		
6.3	Signature:
 
 
 
7.	Additional sheet and Attachments
 
	Check this box if additional sheets and/or attachments are enclosed and indicate the total number of such 
sheets and/or attachments.