Patent Form - Brela

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G.N No. 490 (cont.)
PATENTS ACT. 1987
FOR OFFICIAL USE
FORM NO. 2
Date of Receipt by
(Regulation 8.52)
APPLICATION NO:
To:
The Registrar of Patents
(Office’s Stamp)
Ministry of Industries and Trade
P.O. Box 9393
DAR ES SALAAM -
FILLING DATE:
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REQUEST FOR GRANT OF
PATENT OF UTILITY CERTIFICATE
Applicant’s Agent’s File Reference
-----------------------------------------------------------------------------------------------------------------
THE APPLICANT(S)
REQUEST (S)
PATENT
UTILITY CERTIFICATE
THE GRANT OF
IN RESPECT OF THE FOLLOWING PARTICULARS:
-------------------------------------------------------------------------------------------------------
I.
TITLE OF INVENTION
-------------------------------------------------------------------------------------------------------
II.
APPLICANT(S) (The date a concerning each applicant must appear in this
box or, if the space is insufficient, in the supplemental box). Additional
information is contained in supplemental box.
-------------------------------------------------------------------------------------------------------
Name:
-------------------------------------------------------------------------------------------------------
Address:
------------------------------------------------------------------------------------------------------
Nationality:
------------------------------------------------------------------------------------------------------
Country of residence of principal place of business:
-------------------------------------------------------------------------------------------------------
Telephone number:
Telegraphic Address
Telex Number
III.
AGENT
The following agent has been appointed by the applicant(s) in the power of
attorney.

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