Application for Registration of an Industrial Design

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All personal information created, held or collected by the Canadian Intellectual Property Office is protected under the Privacy Act. This means that you will be informed of the purpose for which it is being collected and how to exercise your right of access to that information. You will be asked for your consent where appropriate.

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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, ___________________________________________________, (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: 1-866-997-1936
Facsimile: 819-953-6977

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