MODEL INTERNATIONAL FORM No. 1

國際授權書格式範本1

FOR OFFICE USE ONLY 

Reference indication of holder/applicant 
and/or licensee: ............................ 

Reference indication of representative of 
holder/applicant: ............................ 
licensee: ............................ 


licensee:1 ............................

僅供主管機關填寫 


註冊持有人/申請人和/或被授權人的 
參考說明：1 ................ 

註冊持有人/申請人之 
代理人的參考說明： ............... 
被授權人代理人的參考說明：1 . ..............

1. Request

• The recordal of the fact that the registration(s) and/or application(s) mentioned in the present request is (are) the subject of a license is hereby requested.
• The amendment of the recordal of the license(s) concerning the registration(s) and/or application(s) mentioned in the present request is hereby requested.
• The cancellation of the recordal of the license(s) concerning the registration(s) and/or application(s) mentioned in the present request is hereby requested.

1.請求書

• 本請求書中提及的註冊和/或申請商標授權使用，特此請求登記。
• 特此請求修正涉及本請求書中提及的註冊和/或申請註冊商標的授權登記。
• 特此請求撤銷涉及本請求書中提及的註冊和/或申請註冊商標的授權登記。

2. Registration(s) and/or Application(s) Concerned

• The present request concerns the following registration(s) and/or application(s):
• 2.1 Registration and/or application number(s):
• 2.2 0 If the space under item 2.1 is not sufficient, check this box and provide the information on an additional sheet.

 2. 所涉的註冊和/或申請

• 本請求書涉及以下註冊和/或申請註冊商標：
• 2.1 註冊號和/或申請號：
• 2.2 0 如第2.1款的空白不夠填寫，請在此格內作標記，並用附頁提供有關的內容。

3. Holder(s)/Applicant(s)

• 3.1 If the holder/applicant is a natural person, the person’s
  • (a) family or principal name:
  • (b) given or secondary name(s):
• 3.2 If the holder/applicant is a legal entity,
  • (a) the entity’s full official designation:
  • (b) the legal nature of the legal entity:
  • (c) the State, and, where applicable, the territorial unit within that State, under the law of which the legal entity is organized:
• 3.3 Address (including postal code and country):
  • Telephone number(s): Telefacsimile numbers(s):4
• 3.4 Check this box if there is more than one holder/applicant; in that case, list the additional holders/applicants on a separate sheet and indicate, in respect of each of them, the data referred to in items 3.1 or 3.2 and 3.3.

3. 註冊持有人/申請人

• 3.1 註冊持有人/申請人若為自然人，請填該自然人的
  • (a) 姓氏：3
  • (b) 名字：3
• 3.2 註冊持有人/申請人若為法人，請填
  • (a) 該法人的正式全名：
  • (b) 該法人的法律性質：
  • (c)該法人係依那一國以及在可適用的情況下該國的那一領土區域的法律所組成的：
• 3.3地址(包括郵遞區號和國家)：
  • 電話號碼：4 傳真號碼：4
• 3.4 註冊持有人/申請人不只一人時，請在此格內作標記；在此情況下，請用附頁將其他持有人/申請人一一列出，並註明每一註冊持有人/申請人的第3.1或3.2款和第3.3款所指的資料。

 4. Representative of Holder(s)/Applicant(s)

• 4.1 Name:
• 4.2 Address (including postal code and country):
  • Telephone number(s): Telefacsimile number(s):5
• 4.3 Registration number, if registered with the Office:
• 4.4 Number allotted to the power of attorney:

4.申請人/持有人的資料

• 4.1 姓名：
• 4.2 地址 (包括郵遞區號和國家)：
  • 電話號碼：5 傳真號碼：5
• 4.3 若已向主管機關註冊，註冊號：
• 4.4 委任書被指定的序號：6

5. Address for Service of Holder(s)/Applicant(s)

5.申請人/持有人的服務地址

6. Licensee

• 6.1 If the licensee is a natural person, the person’s
  • (a) family or principal name:
  • (b) given or secondary name(s):
• 6.2 If the licensee is a legal entity,
  • (a) the entity’s full official designation:
  • (b) the legal nature of the legal entity:
  • (c) the State, and, where applicable, the territorial unit within that State, under the law of which the legal entity is organized:
• 6.3 Address (including postal code and country):
  • Telephone number(s): Telefacsimile numbers(s):8
• 6.4 State of nationality of the licensee:
• 6.5 State of domicile of the licensee:
• 6.6 State of real and effective industrial or commercial establishment of the licensee:
• 6.7 Check this box if there is more than one licensee; in that case, list each additional licensee on a separate sheet and indicate, in respect of each of them, the data referred to in items 6.1 to 6.6.

6. 被授權人

• 6.1 被授權人是自然人的，請填該人的
  • (a) 姓氏：
  • (b) 名字：
• 6.2 被授權人是法人的，請填
  • (a) 該法人的正式全稱：
  • (b) 該法人的法律性質：
  • (c) 該法人係依那一國以及在可適用的情況下該國的那一領土區域的法律所組成的：
• 6.3 地址 (包括郵遞區號和國家)：
  • 電話號碼：8 傳真號碼：8
• 6.4 被授權人的國籍：
• 6.5 被授權人的住所所在國：
• 6.6 被授權人真實有效的工商營業所所在國：
• 6.7 被授權人不只一個時，請在此格內作標記；在此情況下，請用附頁將其他被授權人一一列出，並註明每一被授權人的第6.1至6.6款所指的資料。 

7. Representative of Licensee

• 7.1 Name:
• 7.2 Address (including postal code and country):
  • Telephone number(s): Telefacsimile number(s):9
• 7.3 Registration number, if registered with the Office:
• 7.4 Number allotted to the power of attorney:

7. 被授權人的代理人

• 7.1 姓名：
• 7.2 地址 (包括郵遞區號和國家):
  • 電話號碼：9 傳真號碼：9
• 7.3 已向主管機關註冊，其註冊號：
• 7.4 委任書被指定的序號：10

8. Address for Service of Licensee

8. 被授權人的送達地址

9. Goods and/or Services for Which the License Is Granted

• 9.1 The license is granted for all the goods and/or services listed in the registration(s) and/or application(s) referred to in item 2.
• 9.2 Only one registration and/or application is mentioned in item 2 and the license is only granted for some of the goods and/or services listed in that registration or application. The following goods and/or services are covered by the license:
• 9.3 More than one registration and/or application is mentioned in item 2, and in respect of at least one of them, the license covers less than all the goods and/or services listed. In this case, indicate on an additional sheet, separately in respect of each registration and/or applications, whether the license covers all the goods and/or services or only some of them.

9. 授權的商品和/或服務

• 9.1 第2款所述的註冊和/或申請中列出的全部商品和/或服務上使用。
• 9.2 第2款僅提及一項註冊或申請，僅授權在該註冊或申請中列出的部分商品和/或服務上使用。授權涉及的商品和/或服務如下：
• 9.3 第2款提及的註冊和/或申請不只一個，就其中至少一項註冊和/或申請而言，授權並未涉及所列的全部商品和/或服務。在此情況下，請用附頁分別就每一項註冊和/或申請註明：授權是涉及全部商品和/或服務還是僅涉及部分商品和/或服務。

10. Kind of License

• 10.1 The license is an exclusive license.
• 10.2 The license is a sole license.
• 10.3 The license is a non-exclusive license.
• 10.4 The license concerns only the following part of the territory covered by the registration:

10. 授權的種類

• 10.1 授權是專屬授權。
• 10.2 授權是獨家授權。
• 10.3 授權是非專屬授權。
• 10.4 授權僅涉及註冊所適用的如下領土部分：

11. Time Period of License

• 11.1 The license is limited in time and granted
  • from .......................to ....................... .
  • 11.1.1 The license is subject to automatic extension.
• 11.2 The license is granted for an unlimited period of time.

11. 授權的期限

• 11.1 授權有限期，有效期
  • 自 .......................至 ........................。
  • 11.1.1 授權可自動延期。
• 11.2 授權無限期。

12. Signatures or Seals

• 12.1 Signature(s) or seal(s) of the holder(s)/applicant(s):
  • 12.1.1 Name of the holder/applicant or, if the holder/applicant is a legal entity, name of the person who acts on behalf of the holder/applicant:
  • 12.1.2 Date of signature or of sealing:
  • 12.1.3 Signature or seal:
• 12.2 Signature(s) or seal(s) of the licensee(s):
  • 12.2.1 Name of the licensee(s) or, if the licensee(s) is a legal entity, name of the person who acts on behalf of the licensee(s):
  • 12.2.2 Date of signature or of sealing:
  • 12.2.3 Signature or seal:
• 12.3 Signature or seal of the representative of the holder(s)/applicant(s):
  • 12.3.1 Name of the natural person who signs or whose seal is used:
  • 12.3.2 Date of signature or of sealing:
  • 12.3.3 Signature or seal:
  • 12.4 Signature or seal of the representative of the licensee(s):
    • 12.4.1 Name of the natural person who signs or whose seal is used:
    • 12.4.2 Date of signature or of sealing:
    • 12.4.3 Signature or seal:

12. 簽名或蓋章

• 12.1註冊持有人/申請人的簽名或蓋章：
  • 12.1.1 註冊持有人/申請人的姓名，或註冊持有人/申請人若為法人，註冊持有人/申請人代表人的姓名：
  • 12.1.2 簽名或蓋章的日期：
  • 12.1.3 簽名或蓋章：
• 12.2 被授權人的簽名或蓋章：
  • 12.2.1 被授權人的姓名，或如果被授權人是法人的，代表被授權人的人員的姓名：
  • 12.2.2 簽名日期或蓋章日期：
  • 12.2.3 簽名或蓋章：
• 12.3 註冊持有人/申請人的代理人簽名或蓋章：
  • 12.3.1 簽名或其印章被用來蓋章的自然人姓名：
  • 12.3.2 簽名日期或蓋章的日期：
  • 12.3.3 簽名或蓋章：

13. Fee

• 13.1 Currency and amount of the fee paid in connection with the present request:
• 13.2 Method of payment:

 13. 費用

• 13.1 本請求書應繳費用的貨幣與金額：
• 13.2 付款方式：

14. Additional Sheets

　　Check this box if additional sheets are enclosed and indicate the total number of such sheets:

14. 附頁

　　如此件有附頁，請在此格內作標記，並註明附頁的總頁數：

• 發布日期 : 97-03-29
• 發布單位 : 商標權組
• 更新日期 : 113-07-17
• 瀏覽人次 : 4739