G.N. NO. 490 (contd.
PATENTS ACT, 1987 FOR OFFICIAL USE
Form No. 27 Received on:
(Regulations 39(2) and 52)
To: The Registrar of Patent
Ministry of Industries and Trade
The Patens Office
P.O. Box 9393\
Dar es Salaam.
TANZANIA.
PETITION FOR REGISTRAR OF LICENCE CONTRACT Applicant’s or Agent’s File Reference
PETITION IS HEREBY MADE FOR THE REGISTRATION OF THE FOLLOWING LICENCE
CONTRACT BY THE APPLICATS MENTIONED BELOW IN THE MATTER OF
Patent Application No. ....................................................
Patent No. .......................................................................
Utility Certificate Application No. .................................
Utility Certificate No. .....................................................
1. LICENSOR LICENSEE
Name ............................................................... Name ..........................................................................
Country ........................................................... Country ......................................................................
Address .......................................................... Address ......................................................................
.......................................................................... .....................................................................................
Nationality ..................................................... Nationality: ................................................................
II Trade Business Description Trade or Business Description
.......................................................................... .....................................................................................
.......................................................................... .....................................................................................
.......................................................................... .....................................................................................
III Principal Place of Business Principal Place of Business
Telephone No. .................................................... Telephone No. ...........................................................
Telegraphic Address. ......................................... Telegraphic Address. .................................................
Telex No. ........................................................... Telex No. ....................................................................
IV Principal Technical Field to which the Contract (copy attached) Relates
.....................................................................................................................................................................
.....................................................................................................................................................................
V. Name and Address of Agent (if any) Name and Address of Agent (if any)
.......................................................................... .....................................................................................
.......................................................................... .....................................................................................
.......................................................................... .....................................................................................
VI. Address for Service Address for Service
.......................................................................... .....................................................................................
.......................................................................... .....................................................................................
.......................................................................... .....................................................................................
VII. Signature ...................................................... Signature ....................................................................
Dated.............................................................. Dated .........................................................................
(Licensor) (Licensee)
NOTES:
1. The signature of only the licensor or licensee is sufficient.
2. This form should be accompanied by the prescribed fee.
