COMMUNITY APPLICATION FOR ACTION

1. Date of receipt of the application for action by the designated customs department (within the meaning of Article 5(2) of the Regulation (EC) No 1383/2003)

DD/MM/YY: … /…/…

INTELLECTUAL PROPERTY RIGHTS

APPLICATION FOR ACTION BY CUSTOMS AUTHORITIES

under Article 5(4) of Regulation (EC) No 1383/2003

3. Details of applicant (i.e. right-holder within meaning of Article 2(2) of Regulation (EC) No 1383/2003) (*):

NAME:

FUNCTION:

ADDRESS:

TOWN:

POSTCODE:

COUNTRY:

VAT No:

TEL.:

MOBILE:

FAX:

E-MAIL:

INTERNET ADDRESS:

2. Name and address of competent authority to which application is made:

4. Status of applicant (within the meaning of Article 2(2) of Regulation (EC) No 1383/2003) (1):

Right-holder (*)

Right-holder’s representative (*)

Authorised user of the right (*)

Representative of authorised user (*)

5. Type of right to which application refers:

Community trademark (2)

Community design right (3)

Supplementary protection certificate (4)

Geographical indication protected by the Community (5)

Designation of origin protected by the Community (5)

Community protected plant variety right (6)

Geographical designations for spirit drinks (7)

6. Member State(s) in which action by customs authorities is requested:

BE

EE

IT

HU

PT

SE

BG

IE

CY

MT

RO

UK

CZ

EL

LV

NL

SI

DK

ES

LT

AT

SK

DE

FR

LU

PL

FI

7. I attach essential technical data on the authentic goods:

Number of documents attached (8)

Number of photos attached (8)

8. I attach specific information concerning the type or pattern of fraud:

Number of documents attached (8)

Number of photos attached (8)

COPY FOR THE MEMBER STATE

9. I attach document(s) attesting to the fact that the applicant holds the right for the goods in question within the meaning of Article 2(2) of Regulation (EC) No 1383/2003 (*):

Number of documents attached (8)

10. I attach the undertaking laid down in Article 6 of Regulation (EC) No 1383/2003, assuming liability in the situations outlined in that Article (*):

Undertaking attached:

11. Right-holder’s contact person in the other Member States where action is requested (1):

ADMINISTRATIVE QUESTIONS (lawyer, for example)

BE

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

BG

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

CZ

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

DK

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

DE

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

EE

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

IE

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

EL

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

ES

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

FR

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

IT

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

CY

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

LV

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

LT

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

LU

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

HU

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

MT

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

NL

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

AT

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

PL

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

PT

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

RO

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

SI

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

SK

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

FI

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

SE

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

UK

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

12. Right-holder’s contact person in the other Member States where action is requested (1):

TECHNICAL QUESTIONS (expert, for example)

BE

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

BG

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

CZ

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

DK

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

DE

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

EE

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

IE

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

EL

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

ES

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

FR

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

IT

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

CY

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

LV

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

LT

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

LU

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

HU

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

MT

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

NL

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

AT

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

PL

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

PT

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

RO

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

SI

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

SK

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

FI

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

SE

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

UK

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

13. Any other information in the right-holder’s possession, e.g.:

Country or countries of production

Number of documents attached (8)

Routes used by traffickers

Number of documents attached (8)

Technical differences between the authentic and the suspect goods

Number of documents attached (8)

CN tariff heading

Other useful information

Number of documents attached (8)

14. Date of filing application:

Date on which drawn up

Place

Applicant’s signature (**)

DD/MM/YY: …/…/…

15. Decision by customs authorities (within the meaning of Article 5(7) and (8) of Regulation (EC) No 1383/2003):

The application is approved

Registration number of AA:

Date

DD/MM/YY

Place

Signature and stamp

The application is valid until: …/…/… Any request for extension of the validity period should be sent to the competent authority of Box 2, at the latest 30 working days before the validity of the application expires.

The application has been refused

A reasoned decision stating the grounds for refusal and information concerning the appeal procedure are attached.

Date

DD/MM/YY

Place

Signature and stamp

16. Acknowledgement of receipt:

Concerning application made by (name of the applicant)

BE BG CZ DK DE

EE IE EL ES FR

IT CY LV LT LU

HU MT NL AT PL

PT RO SI SK FI

SE UK

NAME:

PLACE AND DATE OF RECEIPT:

SIGNATURE AND STAMP:

(*) See box 9 (for further information see “Notes on completion”, Annex II-A).

(**) If the applicant is a representative of the right-holder, he must provide proof that he is empowered to represent the right-holder.

(1) Tick the appropriate box(es).

(2) Council Regulation (EC) No 40/94 (OJ L 11, 14.11.1994, p. 1).

(3) Council Regulation (EC) No 6/2002 (OJ L 3, 5.1.2002, p. 1).

(4) Council Regulation (EEC) No 1768/92 or Regulation (EC) No 1610/96 of the European Parliament and of the Council (OJ L 198, 8.8.1996, p. 30).

(5) Council Regulation (EEC) No 2081/92 and (EC) No 1493/99 (OJ L 179, 14.7.1999, p. 1).

(6) Council Regulation (EC) No 2100/94 (OJ L 227, 1.9.1994, p. 1).

(7) Council Regulation (EEC) No 1576/89 (OJ L 160, 12.6.1989, p. 1).

(8) Insert the relevant number; if none are attached, insert 0.

COMMUNITY APPLICATION FOR ACTION

1. Date of receipt of the application for action by the designated customs department (within the meaning of Article 5(2) of the Regulation (EC) No 1383/2003)

DD/MM/YY: … /…/…

INTELLECTUAL PROPERTY RIGHTS

APPLICATION FOR ACTION BY CUSTOMS AUTHORITIES

under Article 5(4) of Regulation (EC) No 1383/2003

3. Details of applicant (i.e. right-holder within meaning of Article 2(2) of Regulation (EC) No 1383/2003) (*):

NAME:

FUNCTION:

ADDRESS:

TOWN:

POSTCODE:

COUNTRY:

VAT No:

TEL.:

MOBILE:

FAX:

E-MAIL:

INTERNET ADDRESS:

2. Name and address of competent authority to which application is made:

4. Status of applicant (within the meaning of Article 2(2) of Regulation (EC) No 1383/2003) (1):

Right-holder (*)

Right-holder's representative (*)

Authorised user of the right (*)

Representative of authorised user (*)

5. Type of right to which application refers:

Community trademark (2)

Community design right (3)

Supplementary protection certificate (4)

Geographical indication protected by the Community (5)

Designation of origin protected by the Community (5)

Community protected plant variety right (6)

Geographical designations for spirit drinks (7)

6. Member State(s) in which action by customs authorities is requested:

BE

EE

IT

HU

PT

SE

BG

IE

CY

MT

RO

UK

CZ

EL

LV

NL

SI

DK

ES

LT

AT

SK

DE

FR

LU

PL

FI

7. I attach essential technical data on the authentic goods:

Number of documents attached (8)

Number of photos attached (8)

8. I attach specific information concerning the type or pattern of fraud:

Number of documents attached (8)

Number of photos attached (8)

COPY FOR THE RIGHT HOLDER

9. I attach document(s) attesting to the fact that the applicant holds the right for the goods in question within the meaning of Article 2(2) of Regulation (EC) No 1383/2003 (*):

Number of documents attached (8)

10. I attach the undertaking laid down in Article 6 of Regulation (EC) No 1383/2003, assuming liability in the situations outlined in that Article (*):

Undertaking attached:

11. Right-holder's contact person in the other Member States where action is requested (1):

ADMINISTRATIVE QUESTIONS (lawyer, for example)

BE

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

BG

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

CZ

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

DK

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

DE

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

EE

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

IE

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

EL

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

ES

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

FR

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

IT

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

CY

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

LV

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

LT

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

LU

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

HU

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

MT

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

NL

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

AT

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

PL

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

PT

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

RO

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

SI

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

SK

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

FI

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

SE

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

UK

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

12. Right-holder’s contact person in the other Member States where action is requested (1):

TECHNICAL QUESTIONS (expert, for example)

BE

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

BG

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

CZ

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

DK

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

DE

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

EE

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

IE

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

EL

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

ES

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

FR

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

IT

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

CY

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

LV

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

LT

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

LU

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

HU

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

MT

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

NL

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

AT

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

PL

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

PT

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

RO

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

SI

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

SK

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

FI

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

SE

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

UK

Name:

Address:

Tel.:

Mobile:

Fax:

E-mail:

See attached list

13. Any other information in the right-holder’s possession, e.g.:

Country or countries of production

Number of documents attached (8)

Routes used by traffickers

Number of documents attached (8)

Technical differences between the authentic and the suspect goods

Number of documents attached (8)

CN tariff heading

Other useful information

Number of documents attached (8)

14. Date of filing application:

Date on which drawn up

Place

Applicant's signature (**)

DD/MM/YY: …/…/…

15. Decision by customs authorities (within the meaning of Article 5(7) and (8) of Regulation (EC) No 1383/2003):

The application is approved

Registration number of AA:

Date

DD/MM/YY

Place

Signature and stamp

The application is valid until: …/…/… Any request for extension of the validity period should be sent to the competent authority of Box 2, at the latest 30 working days before the validity of the application expires.

The application has been refused

A reasoned decision stating the grounds for refusal and information concerning the appeal procedure are attached.

Date

DD/MM/YY

Place

Signature and stamp

16. Acknowledgement of receipt:

Concerning application made by (name of the applicant)

BE BG CZ DK DE

EE IE EL ES FR

IT CY LV LT LU

HU MT NL AT PL

PT RO SI SK FI

SE UK

NAME:

PLACE AND DATE OF RECEIPT:

SIGNATURE AND STAMP:

(*) See box 9 (for further information see “Notes on completion”, Annex II-A).

(**) If the applicant is a representative of the right-holder, he must provide proof that he is empowered to represent the right-holder.

(1) Tick the appropriate box(es).

(2) Council Regulation (EC) No 40/94 (OJ L 11, 14.11.1994, p. 1).

(3) Council Regulation (EC) No 6/2002 (OJ L 3, 5.1.2002, p. 1).

(4) Council Regulation (EEC) No 1768/92 or Regulation (EC) No 1610/96 of the European Parliament and of the Council (OJ L 198, 8.8.1996, p. 30).

(5) Council Regulation (EEC) No 2081/92 and (EC) No 1493/99 (OJ L 179, 14.7.1999, p. 1).

(6) Council Regulation (EC) No 2100/94 (OJ L 227, 1.9.1994, p. 1).

(7) Council Regulation (EEC) No 1576/89 (OJ L 160, 12.6.1989, p. 1).

(8) Insert the relevant number; if none are attached, insert 0.’