Form 16

First Schedule (Section 100(2) and 103(i))

Application to register an assignment, licence, mergers, change of name or change of address

1. Reference

Your Reference:

2. Application or registration number(s):

Choose the Patent Type

3. Applicant/Proprietor

Full Name of the each applicant or proprietor (as currently on the register or application). *:

4. Full Name and Address of each person acquiring the rights:

Name *:
Address *:

5. Give details of the transaction, instrument or even which affects the rights in the application or registration identified includings ots date and the names of all paries involved:

Your Reference:

6. Agent

Name:
Email Address:
Telephone Number:

7. Declaration

1/We hereby confirm that rights as indicated in 5 above hae been acquired and that any necessary stamp duty has been paid.

8. Cost and transaction date:

Application Fee $:
Application Date:

9. Contact

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