Copyright and Industrial Design Branch Place du Portage I 50 Victoria Street Gatineau Quebec K1A OC9 Telephone: (819) 997-1936 Facsimile: (819) 953-6977 APPLICATION FOR REGISTRATION OF AN INDUSTRIAL DESIGN [ Français ] The applicant, ___________________________________________________, (name of applicant) whose complete address is _________________________________________ _______________________________________________________________, hereby requests registration of a design for a ___________________________ (title identifying article) 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 Name of agent Address of 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. Name of representative for service Address in Canada of representative for service     Copyright and Industrial Design Branch Place du Portage I 50 Victoria Street Gatineau Quebec K1A OC9 Telephone: (819) 997-1725 Facsimile: (819) 953-6977

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