Designs Act, 1993 (Act No. 195 of 1993)

Design No.:

Date of lodgement

Full name(s) of registered proprietor(s):

Type of design

Part A

Part F

I / We ...................................................................................................................................................................................................................................

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1.

(a)

I/we am/are the proprietor(s) mentioned above;

1.

(b)

I/we am/are authorised by the proprietor(s) to make this offer;

2.

I/We hereby offer to surrender the above-mentioned design registration;

3.

no action for infringement or proceedings for revocation of the design are pending except as set out below; and

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4.

the reasons for making this offer are as follows:

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FOR OFFICIAL USE ONLY

The above offer to surrender has been allowed/refused

Official date stamp

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