Patents Act, 1978 (Act No. 57 of 1978)

Regulations

Purchase

Form P21

REPUBLIC OF SOUTH AFRICA

PATENTS ACT, 1978

APPLICATION FOR THE VOLUNTARY SURRENDER OF A PATENT

(Section 64(1) - Regulation 67)

R20

Official date stamp

Patent No.				Lodging date
21	01			22

Full name(s) of patentee(s)

Full address(es) of patentee(s)

Title of invention
54

I/We,…………………………………………………………………………………………………….................................................................

..................................................................…………………………………………………………………………………………………………..

hereby declare that—

1.	I/We am/are the patentee(s) mentioned above;

2.	I/We hereby offer to surrender the above-mentioned patent;

3.	No action for infringement or proceedings for revocation of the patent are pending; and

4.	My/our reasons for making this offer are as follows

……………………………………………………………………………………………………..............................................................

74	Address for service

Dated this…………………………………………………… day of………… 20…………

………………………..…

Signature