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Page 1: FORMULIR PERMOHONAN PENDAFTARAN MEREK … · form tme-001 formulir permohonan pendaftaran merek indonesia application form of trademark registration of indonesia data permohonan (application)

Form TMe-001

FORMULIR PERMOHONAN PENDAFTARAN MEREK INDONESIAAPPLICATION FORM OF TRADEMARK REGISTRATION OF INDONESIA

Data Permohonan (Application)

Nomor e-FilingNumber of e-Filing

: WFT2017XXXXXX Tanggal PermohonanDate of Submission

: 2017-12-01

Nomor PermohonanNumber of Application

: D I D / J I D 2 0 1 7 X X X X X X Jenis PermohonanType of Application

: Merek Dagang Non UMKM

Rincian Merek (Description of Mark)Nama MerekName of Mark

: HANYA CONTOH BELAKA Etiket GambarImage of Mark

ArtiMeaning

: Hanya Sebuah Penamaan

WarnaColors

: Merah, Putih, Biru, Hitam, Abu-abu

DiclaimerDisclaimer

: -

Pemohon (Applicant)

Nama (Name) Alamat (Address) Surel/Telp. (Email/Phone)

Nama / Badan Hukum Jl. xxxx

Kuasa/Konsultan KI (Representative/IP Consultant)

Nama (Name) Alamat (Address) Surel/Telp. (Email/Phone)

Nama Konsultan HKI Jl. xxxx

Kelas Barang/Jasa (Classs of Goods / Services)Kode (Class) Jenis Barang/Jasa (Description of Goods/Services)

1 s/d 45 Jenis barang 1; Jenis barang 2; dst

Data Prioritas (Priority Data)

Negara (Country) Nomor (Number) Tanggal (Date)

Lampiran (Attachments)Salinan Sah Akta Pendirian Badan HukumSurat KuasaSurat Pernyataan KepemilikanFotokopi KTP

Jakarta, 2017-12-01 Pemohon / Kuasa Applicant / Representative

Tanda tangan / SignatureNama lengkap / Full Name Nama Konsultan HKI

Dibubuhi Tanda Tangan Digital Oleh Direktorat Jenderal Kekayaan Intelektual (DJKI) pada tanggal tsb.<