Form 11

First Schedule (Section 76(1))

Application to convert a patent application to utility model application or utility model application to a patent application

1. Reference

Your Reference:

2. Patent/utility model application or patent/utility model number(s) to which the proceedings relate:

Number *:

3. Applicant/Proprietor

Full Name of the Applicant or each applicant or proprietor. *:

4. Intitiators

Name *:
Address *:
Email Address *:

5. Agent

Name:
Email Address:
Telephone Number:

6. Cost and Date

Application Fee $:
Application Date:

7. Contact

8. Contact's Name *:
Contact's Address:
Contact's Telephone Number:
Contact's Email Address: