EUROPEAN UNION — APPLICATION FOR ACTION

1

1. Applicant

Name (*):

Address (*):

Town (*):

Postal Code:

Country (*):

EORI-No: (+)

TIN No: (+)

National registration No: (+)

Telephone: (+)

Mobile: (+)

Fax: (+)

Email (*):

Website:

For official use

Date of receipt

COPY FOR THE COMPETENT CUSTOMS DEPARTMENT

Registration number of application

INTELLECTUAL PROPERTY RIGHTS

APPLICATION FOR ACTION BY CUSTOMS AUTHORITIES

under Article 6 of Regulation (EU) No 608/2013

2 (*). Union application

National application

National application (cf. Article 5(3))

3 (*). Status of applicant

Right-holder

Person or entity authorised to use the IP right

IP collective rights management body

Professional defence body

Group of producers of products with a Geographical Indication or representative of such group

Operator entitled to use a Geographical Indication

Inspection body or authority competent for a Geographical Indication

Exclusive license holder covering two or more Member States

4. Representative submitting the application in the name of the applicant

Company:

Name (*):

Address (*):

Town (*):

Postal Code:

Country (*):

Telephone: (+)

Mobile: (+) Evidence of the representatives power to act is enclosed

Fax: (+)

1

5 (*). Type of right to which the application refers

National trademark (NTM)

European Union trademark (EUTM)

International registered trademark (ITM)

Registered national design (ND)

Registered Community design (CDR)

International registered design (ICD)

Unregistered Community design (CDU)

Copyright and related right (NCPR)

Trade name (NTN)

Topography of semiconductor product (NTSP)

Patent as provided for by national law (NPT)

Patent as provided for by Union law (UPT)

Utility model (NUM)

Geographical Indication/Designation of origin:

for agricultural products and foodstuff (CGIP)

for wine (CGIW)

for aromatised drinks based on wine products (CGIA)

for spirit drinks (CGIS)

for other products (NGI)

as listed in Agreements between the Union and third countries (CGIL)

Plant variety right:

national (NPVR)

Community (CPVR)

Supplementary protection certificate:

for medicinal products (SPCM)

for plant protection products (SPCP)

6 (*). Member State or, in the case of a Union application, Member States in which customs action is requested

ALL MEMBER STATES

BE

LT

BG

LU

CZ

HU

DK

MT

DE

NL

EE

AT

IE

PL

EL

PT

ES

RO

FR

SI

HR

SK

IT

FI

CY

SE

LV

UK

7. Representative for legal matters

Company:

Name (*):

Address (*):

Town (*):

Postal Code:

Country (*):

Telephone: (+)

Mobile: (+)

Fax: (+)

Email (*):

Website:

8. Representative for technical matters

Company:

Name (*):

Address (*):

Town (*):

Postal Code:

Country (*):

Telephone: (+)

Mobile: (+)

Fax: (+)

Email (*):

Website:

9. In case of a Union application, the details of the designated representatives for legal and technical matters are included in annex no

10. I request the use of the procedure of Article 26 of Regulation (EU) No 608/2013 (small consignments) in the following Member State(s) and, where requested by the customs authorities, agree to cover the costs related to the destruction of goods under this procedure.

ALL MEMBER STATES

BE

LT

BG

LU

CZ

HU

DK

MT

DE

NL

EE

AT

IE

PL

EL

PT

ES

RO

FR

SI

HR

SK

IT

FI

CY

SE

LV

UK

(*) these are mandatory fields and shall be filled in

(+) at least one of these fields shall be filled in

11 (*). List of rights to which the application refers

No

Type of right

Registration number

Date of registration

Expiry date

List of goods to which the right refers

For further rights see annex no Restricted handling

Authentic goods

12 (*). Goods details Restricted handling

IP right no:

Goods description:

CN tariff number:

Customs value:

European average market value:

National market value: See enclosed annex no

13 (*). Goods distinctive features Restricted handling

Position on the goods:

Description:

See enclosed annex no

14 (*). Place of production Restricted handling

Country:

Company:

Address:

Town: See enclosed annex no

15 (*). Involved companies Restricted handling

Role:

Name:

Address:

Town:

Postal Code:

Country: See enclosed annex no

16 (*). Traders Restricted handling

Name:

Address:

Town:

Postal Code:

Country: See enclosed annex no

17. Goods clearance details and distribution information Restricted handling

See enclosed annex no

18. Packages Restricted handling

Kind of packages:

Number of items per package:

Description (incl. distinctive features):

See enclosed annex no

19. Accompanying documents Restricted handling

Type of document:

Description:

See enclosed annex no

Infringing goods

20. Goods details Restricted handling

IP right no:

Goods description:

CN tariff number:

Minimum value: See enclosed annex no

21. Goods distinctive features Restricted handling

Position on the goods:

Description:

See enclosed annex no

22. Place of production Restricted handling

Country:

Company:

Address:

Town:

Postal Code:

See enclosed annex no

23. Involved companies Restricted handling

Role:

Name:

Address:

Town:

Postal Code:

Country: See enclosed annex no

24. Traders Restricted handling

Name:

Address:

Town:

Postal Code:

Country:

See enclosed annex no

25. Goods distribution information Restricted handling

See enclosed annex no

26. Packages Restricted handling

Kind of packages:

Number of items per package:

Description (incl. distinctive features):

See enclosed annex no

27. Accompanying documents Restricted handling

Type of document:

Description:

See enclosed annex no

28. Additional information Restricted handling

See enclosed annex no

29. Undertakings

By signing I undertake to:

— notify immediately the competent customs department that granted this application of any change in the information provided by me within this application or attachments in accordance with Article 15 of Regulation (EU) No 608/2013.

— forward to the competent customs department that granted this application any update on the information as referred to in point (g), (h) or (i) of Article 6(3) of Regulation (EU)No 608/2013 that are relevant to customs authorities' analysis and assessment of the risk of infringement of the intellectual property right(s) included in this application.

— assume liability under the conditions laid down in Article 28 of Regulation (EU) No 608/2013 and bear the costs as referred to in Article 29 of Regulation (EU) No 608/2013.

I agree that all the data submitted with this application may be processed by the European Commission and by the Member States.

30 (*). Signature

Date (DD/MM/YYYY) Applicant's signature

Place Name (Block capitals)

For official use

Decision by customs authorities (within the meaning of Section 2 of Regulation (EU) No 608/2013)

The application is completely granted.

The application has been partially granted (for the granted rights see attached list).

Date of adoption (DD/MM/YYYY) Signature and stamp Competent customs department

Expiry date of the application:

Any request for extension of the period that customs authorities are to take action should be received by the competent customs department at the latest 30 working days before the expiry date.

The application has been rejected.

A reasoned decision stating the grounds for partial or complete rejection and information concerning the appeal procedure are attached.

Date (DD/MM/YYYY) Signature and stamp Competent customs department

Personal data protection and the central database for the processing of applications for action.

Where the European Commission processes personal data contained in this application for action Regulation (EC) No 45/2001 of the European Parliament and of the Council on the protection of individuals with regard to the processing of personal data by the Community Institutions and bodies and on the free movement of such data will apply. Where the competent customs authority of a Member State processes personal data contained in this application for action the national provisions implementing Directive 95/46/EC will apply.

The purpose of the processing of personal data of the application for action is the enforcement of intellectual property rights by customs authorities in the Union in accordance with Regulation (EU) No 608/2013 of the European Parliament and of the Council of 12 June 2013 concerning customs enforcement of intellectual property rights.

The controller with respect to the processing of the data in the central database is the national competent customs department where the application has been submitted.The list of competent customs departments is published on the website of the Commission:

http://ec.europa.eu/taxation_customs/customs/customs_controls/counterfeit_piracy/right_holders/index_en.htm.

The access to all personal data of this application is granted through UserID/Password to customs authorities in the Member States and the Commission.

Personal data forming part of the information that falls under restricted handling will only be accessible by customs authorities of the Member States as indicated in box 6 of the application through UserID/Password.

In accordance with Article 22 of Regulation (EU) No 608/2013, without prejudice to applicable provisions on data protection in the Union and for the purpose of contributing to eliminating international trade in goods infringing intellectual property rights, the Commission and the customs authorities of the Member States may share personal data and information contained in the application with the relevant authorities in third countries.

Replies to data fields marked with an * and to at least one of the fields marked "+" are obligatory to be filled in. In case of failure to fill in these obligatory data, the application shall be rejected.

The data subject has a right of access to the personal data relating to him or her that will be processed through the central database and, where appropriate, the right to rectify, erase or block personal data in accordance with Regulation (EC) No 45/2001 or the national laws implementing Directive 95/46/EC.

All requests for the exercise of the right of access, rectification, erasure or blocking shall be submitted to and processed by the competent customs department where the application was submitted.

The legal basis for processing the personal data for the enforcement of intellectual property rights is Regulation (EU) No 608/2013 of the European Parliament and of the Council of12 June 2013 concerning customs enforcement of intellectual property rights.

Personal data shall not be stored longer than six months from the date the decision granting the application has been revoked or the relevant period during which customs authorities are to take action has expired. That period shall be specified by the competent customs department when granting the application and shall not exceed one year from the day following the date of adoption of the decision granting the application. However, where customs authorities have been notified of proceedings initiated to determine a possible infringement of goods under the application, personal data shall be kept for six months after the proceedings have been concluded.

Complaints, in case of conflict, can be addressed to the relevant national data protection authority. The contact details of the national data protection authorities are available on the web-site of the European Commission, Directorate General for Justice (http://ec.europa.eu/justice/data-protection/bodies/authorities/eu/index_en.htm#h2-1). Where the complaint concerns processing of personal data by the European Commission, it should be addressed to the European Data Protection Supervisor (http://www.edps.europa.eu/EDPSWEB/).

EUROPEAN UNION — APPLICATION FOR ACTION

2

1. Applicant

Name (*):

Address (*):

Town (*):

Postal Code:

Country (*):

EORI-No: (+)

TIN No: (+)

National registration No: (+)

Telephone: (+)

Mobile: (+)

Fax: (+)

Email (*):

Website:

For official use

Date of receipt

COPY FOR THE APPLICANT

Registration number of application

INTELLECTUAL PROPERTY RIGHTS

APPLICATION FOR ACTION BY CUSTOMS AUTHORITIES

under Article 6 of Regulation (EU) No 608/2013

2 (*). Union application

National application

National application (cf. Article 5(3))

3 (*). Status of applicant

Right-holder

Person or entity authorised to use the IP right

IP collective rights management body

Professional defence body

Group of producers of products with a Geographical Indication or representative of such group

Operator entitled to use a Geographical Indication

Inspection body or authority competent for a Geographical Indication

Exclusive license holder covering two or more Member States

4. Representative submitting the application in the name of the applicant

Company:

Name (*):

Address (*):

Town (*):

Postal Code:

Country (*):

Telephone: (+)

Mobile: (+) Evidence of the representatives power to act is enclosed

Fax: (+)

2

5 (*). Type of right to which the application refers

National trademark (NTM)

European Union trademark (EUTM)

International registered trademark (ITM)

Registered national design (ND)

Registered Community design (CDR)

International registered design (ICD)

Unregistered Community design (CDU)

Copyright and related right (NCPR)

Trade name (NTN)

Topography of semiconductor product (NTSP)

Patent as provided for by national law (NPT)

Patent as provided for by Union law (UPT)

Utility model (NUM)

Geographical Indication/Designation of origin:

for agricultural products and foodstuff (CGIP)

for wine (CGIW)

for aromatised drinks based on wine products (CGIA)

for spirit drinks (CGIS)

for other products (NGI)

as listed in Agreements between the Union and third countries (CGIL)

Plant variety right:

national (NPVR)

Community (CPVR)

Supplementary protection certificate:

for medicinal products (SPCM)

for plant protection products (SPCP)

6 (*). Member State or, in the case of a Union application, Member States in which customs action is requested

ALL MEMBER STATES

BE

LT

BG

LU

CZ

HU

DK

MT

DE

NL

EE

AT

IE

PL

EL

PT

ES

RO

FR

SI

HR

SK

IT

FI

CY

SE

LV

UK

7. Representative for legal matters

Company:

Name (*):

Address (*):

Town (*):

Postal Code:

Country (*):

Telephone: (+)

Mobile: (+)

Fax: (+)

Email (*):

Website:

8. Representative for technical matters

Company:

Name (*):

Address (*):

Town (*):

Postal Code:

Country (*):

Telephone: (+)

Mobile: (+)

Fax: (+)

Email (*):

Website:

9. In case of a Union application, the details of the designated representatives for legal and technical matters are included in annex no

10. I request the use of the procedure of Article 26 of Regulation (EU) No 608/2013 (small consignments) in the following Member State(s) and, where requested by the customs authorities, agree to cover the costs related to the destruction of goods under this procedure.

ALL MEMBER STATES

BE

LT

BG

LU

CZ

HU

DK

MT

DE

NL

EE

AT

IE

PL

EL

PT

ES

RO

FR

SI

HR

SK

IT

FI

CY

SE

LV

UK

(*) these are mandatory fields and shall be filled in

(+) at least one of these fields shall be filled in

11 (*). List of rights to which the application refers

No

Type of right

Registration number

Date of registration

Expiry date

List of goods to which the right refers

For further rights see annex no Restricted handling

Authentic goods

12 (*). Goods details Restricted handling

IP right no:

Goods description:

CN tariff number:

Customs value:

European average market value:

National market value: See enclosed annex no

13 (*). Goods distinctive features Restricted handling

Position on the goods:

Description:

See enclosed annex no

14 (*). Place of production Restricted handling

Country:

Company:

Address:

Town: See enclosed annex no

15 (*). Involved companies Restricted handling

Role:

Name:

Address:

Town:

Postal Code:

Country: See enclosed annex no

16 (*). Traders Restricted handling

Name:

Address:

Town:

Postal Code:

Country: See enclosed annex no

17. Goods clearance details and distribution information Restricted handling

See enclosed annex no

18. Packages Restricted handling

Kind of packages:

Number of items per package:

Description (incl. distinctive features):

See enclosed annex no

19. Accompanying documents Restricted handling

Type of document:

Description:

See enclosed annex no

Infringing goods

20. Goods details Restricted handling

IP right no:

Goods description:

CN tariff number:

Minimum value: See enclosed annex no

21. Goods distinctive features Restricted handling

Position on the goods:

Description:

See enclosed annex no

22. Place of production Restricted handling

Country:

Company:

Address:

Town:

Postal Code:

See enclosed annex no

23. Involved companies Restricted handling

Role:

Name:

Address:

Town:

Postal Code:

Country: See enclosed annex no

24. Traders Restricted handling

Name:

Address:

Town:

Postal Code:

Country:

See enclosed annex no

25. Goods distribution information Restricted handling

See enclosed annex no

26. Packages Restricted handling

Kind of packages:

Number of items per package:

Description (incl. distinctive features):

See enclosed annex no

27. Accompanying documents Restricted handling

Type of document:

Description:

See enclosed annex no

28. Additional information Restricted handling

See enclosed annex no

29. Undertakings

By signing I undertake to:

— notify immediately the competent customs department that granted this application of any change in the information provided by me within this application or attachments in accordance with Article 15 of Regulation (EU) No 608/2013.

— forward to the competent customs department that granted this application any update on the information as referred to in point (g), (h) or (i) of Article 6(3) of Regulation (EU)No 608/2013 that are relevant to customs authorities' analysis and assessment of the risk of infringement of the intellectual property right(s) included in this application.

— assume liability under the conditions laid down in Article 28 of Regulation (EU) No 608/2013 and bear the costs as referred to in Article 29 of Regulation (EU) No 608/2013.

I agree that all the data submitted with this application may be processed by the European Commission and by the Member States.

30 (*). Signature

Date (DD/MM/YYYY) Applicant's signature

Place Name (Block capitals)

For official use

Decision by customs authorities (within the meaning of Section 2 of Regulation (EU) No 608/2013)

The application is completely granted.

The application has been partially granted (for the granted rights see attached list).

Date of adoption (DD/MM/YYYY) Signature and stamp Competent customs department

Expiry date of the application:

Any request for extension of the period that customs authorities are to take action should be received by the competent customs department at the latest 30 working days before the expiry date.

The application has been rejected.

A reasoned decision stating the grounds for partial or complete rejection and information concerning the appeal procedure are attached.

Date (DD/MM/YYYY) Signature and stamp Competent customs department

Personal data protection and the central database for the processing of applications for action.

Where the European Commission processes personal data contained in this application for action Regulation (EC) No 45/2001 of the European Parliament and of the Council on the protection of individuals with regard to the processing of personal data by the Community Institutions and bodies and on the free movement of such data will apply. Where the competent customs authority of a Member State processes personal data contained in this application for action the national provisions implementing Directive 95/46/EC will apply.

The purpose of the processing of personal data of the application for action is the enforcement of intellectual property rights by customs authorities in the Union in accordance with Regulation (EU) No 608/2013 of the European Parliament and of the Council of 12 June 2013 concerning customs enforcement of intellectual property rights.

The controller with respect to the processing of the data in the central database is the national competent customs department where the application has been submitted.The list of competent customs departments is published on the website of the Commission:

http://ec.europa.eu/taxation_customs/customs/customs_controls/counterfeit_piracy/right_holders/index_en.htm.

The access to all personal data of this application is granted through UserID/Password to customs authorities in the Member States and the Commission.

Personal data forming part of the information that falls under restricted handling will only be accessible by customs authorities of the Member States as indicated in box 6 of the application through UserID/Password.

In accordance with Article 22 of Regulation (EU) No 608/2013, without prejudice to applicable provisions on data protection in the Union and for the purpose of contributing to eliminating international trade in goods infringing intellectual property rights, the Commission and the customs authorities of the Member States may share personal data and information contained in the application with the relevant authorities in third countries.

Replies to data fields marked with an * and to at least one of the fields marked "+" are obligatory to be filled in. In case of failure to fill in these obligatory data, the application shall be rejected.

The data subject has a right of access to the personal data relating to him or her that will be processed through the central database and, where appropriate, the right to rectify, erase or block personal data in accordance with Regulation (EC) No 45/2001 or the national laws implementing Directive 95/46/EC.

All requests for the exercise of the right of access, rectification, erasure or blocking shall be submitted to and processed by the competent customs department where the application was submitted.

The legal basis for processing the personal data for the enforcement of intellectual property rights is Regulation (EU) No 608/2013 of the European Parliament and of the Council of12 June 2013 concerning customs enforcement of intellectual property rights.

Personal data shall not be stored longer than six months from the date the decision granting the application has been revoked or the relevant period during which customs authorities are to take action has expired. That period shall be specified by the competent customs department when granting the application and shall not exceed one year from the day following the date of adoption of the decision granting the application. However, where customs authorities have been notified of proceedings initiated to determine a possible infringement of goods under the application, personal data shall be kept for six months after the proceedings have been concluded.

Complaints, in case of conflict, can be addressed to the relevant national data protection authority. The contact details of the national data protection authorities are available on the web-site of the European Commission, Directorate General for Justice (http://ec.europa.eu/justice/data-protection/bodies/authorities/eu/index_en.htm#h2-1). Where the complaint concerns processing of personal data by the European Commission, it should be addressed to the European Data Protection Supervisor (http://www.edps.europa.eu/EDPSWEB/).