Application for Registration of an Industrial Design

Copyright and Industrial
Design Branch
Place du Portage I
50 Victoria Street
Gatineau Quebec K1A OC9
Telephone: 1-866-997-1936
Facsimile: 819-953-6977

The applicant,
___________________________________________________,

whose complete address is
_________________________________________
_______________________________________________________________,
hereby requests registration of a design for a
___________________________

of which the applicant is the proprietor.

The design was not, to the proprietor's knowledge, in use by any person
other than the first proprietor at the time the design was adopted by the
first proprietor.

Description of the design:

To be completed only if an applicant has an agent

If an applicant has no place of business in Canada, the name and address of a REPRESENTATIVE FOR SERVICE in Canada must be provided.

Copyright and Industrial
Design Branch
Place du Portage I
50 Victoria Street
Gatineau Quebec K1A OC9
Telephone: 1-866-997-1936
Facsimile: 819-953-6977