(REQUEST FOR REGISTRATION)
This is a request for registration of a mark reproduced in this form.

APPLICATION DATA FORM

APPLICANT

Select an option*

Name*

Full Address*

NRC No./ Passport No./ Organization
(Company) Registration No*

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State of a real and effective industrial or commercial establishment

State of Nationality/ Incorporation Country
(The State, and, where applicable, the territorial unit within that State, under the law of which the legal entity is organized)