By signing this form, I declare that I am entitled to sign it under the applicable law: Name: Signature: FEE CALCULATION SHEET (a) INSTRUCTIONS TO DEBIT FROM A CURRENT ACCOUNT The International Bureau is hereby instructed to debit the required amount of fees from a current account opened with the International Bureau (if this box is checked, it is not necessary to complete (b)). Holder of the account: Account number: Identity of the party giving the instructions: (b) AMOUNT OF FEES (653 Swiss francs) Basic fee Where applicable, surcharge for the grace period (326.50 Swiss Francs) Complementary and supplementary fees: Number of designations for which complementary fee is Total amount of the applicable Complementary fee complementary fees x 100 Swiss francs = => Number of classes of goods and services Total amount of the beyond three Supplementary fee supplementary fees x 100 Swiss francs = => Individual fees (Swiss francs): Designated Contracting Individual fee Designated Contracting Parties Individual fee Parties Total individual fees => Grand total (Swiss francs) (c) METHOD OF PAYMENT Identity of the party effecting the payment: WIPO receipt number Payment received and acknowledged by WIPO Payment made to WIPO bank account Payment identification dd/mm/yyyy IBAN No. CH51 0483 5048 7080 8100 0 Crédit Suisse, CH-1211 Geneva 70 Swift/BIC: CRESCHZZ80A
By signing this form, I declare that I am entitled to sign it under the applicable law: Name: Signature: FEE CALCULATION SHEET (a) INSTRUCTIONS TO DEBIT FROM A CURRENT ACCOUNT The International Bureau is hereby instructed to debit the required amount of fees from a current account opened with the International Bureau (if this box is checked, it is not necessary to complete (b)). Holder of the account: Account number: Identity of the party giving the instructions: (b) AMOUNT OF FEES Basic fee (653 Swiss francs) Where applicable, surcharge for the grace period (326.50 Swiss Francs) Complementary and supplementary fees: Number of designations for which complementary fee is applicable x Complementary fee 100 Swiss francs Total amount of the complementary fees = => Number of classes of goods and services beyond three x Supplementary fee 100 Swiss francs Total amount of the supplementary fees = => Individual fees (Swiss francs): Designated Contracting Parties Individual fee Designated Contracting Parties Individual fee Total individual fees => Grand total (Swiss francs) (c) METHOD OF PAYMENT Identity of the party effecting the payment: Payment received and acknowledged by WIPO WIPO receipt number Payment made to WIPO bank account IBAN No. CH51 0483 5048 7080 8100 0 Crédit Suisse, CH-1211 Geneva 70 Swift/BIC: CRESCHZZ80A Payment identification dd/mm/yyyy
form_mm11.docx