Form 4

(Section 13(2))

Information on a foreign patent application

1. Your Reference :
2. Local patent application/registration number:
3. Foreign patent application/registration number or publication number of applicaton: :
4. Proprietor's Name of the foreign patent *:
5. Mailing Address for Service *:
Email Address *:
6. The particular information being submitted: Not Limited to 13(2(a),(b),(c),and (d):
Application Fee $:
Processing Date:
Notes
A. This form may be used for more than one application or patent if the sam authorization has been given.