Last updated: 07/2013 OFFICE FOR HARMONIZATION IN THE INTERNAL MARKET (OHIM) Number of pages (including this one) 1. Applicant/representative reference (not more than 20 characters) 2. CTM application/registration number No 3. Mod.010 APPLICATION FOR CONVERSION Verbal part of the mark (if appropriate) Language BG ES CS DA DE ET EL EN HR FR IT LV LI HU MT NL PL PT RO SK SL FI SV 4. Applicant ID number legal entity Name of legal entity or Legal form of the entity first name and surname 5. Representative natural person ID number Name for verification Type of representative 6. legal practitioner OHIM representative association of representatives Ground for conversion 7. Member State(s) Date of communication from the Office: ___ / ___ / ______ The Community trade mark application has been withdrawn ___ / ___ / ______ Date of withdrawal of application: The Community trade mark application has been refused by a decision of the Office ___ / ___ / ______ Date of the decision: The Community trade mark registration has ceased to have effect as a result of a decision by the Office ___ / ___ / ______ Date of the decision: The Community trade mark registration has been surrendered Date of entry of the surrender in the Register: ___ / ___ / ______ The Community trade mark registration has not been renewed ___ / ___ / ______ Date of expiry of protection: The Community trade mark registration has ceased to have effect as a result of a decision of a Community trade mark court Date when decision became final: Copy of decision attached ___ / ___ / ______ Total Current account with OHIM 9. Payment of fees € 200 Do not use my current account with OHIM BG GR CY PL SE BX ES LV PT GB CZ FR MT RO DK HR LT SI DE IE HU SK EE IT AT FI Banco Bilbao Vizcaya Argentaria #TM010EN / / Priority / seniority Priority was claimed for some or all the goods/ services of the CTM application Seniority was claimed for some or all the goods/ services contained in the earlier registration I request the OHIM to communicate relevant information relating to the above mentioned Community trade mark application or registration contained in its data base to the central industrial property offices of the specified Member States, according to Art. 113 CTMR and Rules 44 and 47 CTMIR. 10. Signature Signature Transfer to account of OHIM Date of transfer (DD/MM/YYYY) 8. Name Account No La Caixa The Community trade mark application has been deemed withdrawn employee Complete this page only if partial conversion is requested APPLICATION FOR CONVERSION List of goods and services #TM010EN Class No attached list of goods and services ANNEX TO THE CONVERSION FORM National representation (before the national Office) Country Name BG BX CZ DK DE GR ES FR PT RO SI SK FI SE GB HR IE IT CY LV LT HU LT HU LT HU EE AT MT EE AT MT EE AT MT PL Tel, fax, e-mail Address Street and number City and postal code Country Postal address (if different) National representation (before the national Office) Country Name BG BX CZ DK DE GR ES FR PT RO SI SK FI SE GB HR IE IT CY LV PL Tel, fax, e-mail Address Street and number City and postal code Country Postal address (if different) National representation (before the national Office) Country Name BG BX CZ DK DE GR ES FR PT RO SI SK FI SE GB HR IE IT CY LV Tel, fax, e-mail Address Street and number City and postal code #TM010EN Country Postal address (if different) If the space provided is not sufficient, make further copies of this page Reset form PL