Sample How to Fill up This Form

Sample how to fill up this form

CENTRALGEOGRAPHICALINDICATIONSOFFICEMALAYSIA

GEOGRAPHICALINDICATIONSREGISTRY

GEOGRAPHICALINDICATIONACT2000

GEOGRAPHICALINDICATIONSREGULATIONS2001

APPLICATION FOR REGISTRATION OF A GEOGRAPHICAL INDICATION (Subregulation 6(1))
TO: TheRegistrarofGeographicalIndications CentralGeographicalIndicationsOffice KualaLumpur,Malaysia / ForOfficialUse:
Date of Receipt by
CentralGeographicalIndicationsOffice:
APPLICATION NO.:
(Office’s Stamp)
Fees received on: Amount:
Applicant’sorAgent’sFileReference
THE APPLICANT REQUEST FOR THE REGISTRATION OF A GEOGRAPHICAL
INDICATION IN RESPECT OF THE FOLLOWING PARTICULARS:
I.Fullnameandaddressofapplicant: …………..{Producer/Competent authority/trade
organization or association}……………………………………………………… (Iftheapplicantresidesabroad,anaddressforserviceinMalaysiamustbeprovided)
Nationality:{Citizenship}
Country of Residence or
principal place of business: {Name of places that produce that GI)
Capacityinwhichapplicant is
applying forregistration: {Position applicant)
Tel No:Telegraphic Address:Telex No:Fax No:
II.Fullnameandaddressof agent(ifany): ……{For registered agent only}……
…………………………………………………………………………………………………..
………………………………………………………………………………………………….. (Ifthisistheaddressforserviceandisnotalreadyonrecord,FormGI1mustbefiledwiththis Form)
Agent’sRegistration(ifknown): …………{For registered agent only}…………
Agent’s ownreference: ……….…{For registered agent only}……………..
Tel No:Telegraphic Address:Telex No:Fax No:
III.GEOGRAPHICAL INDICATION :
Thegeographicalindicationforwhichregistrationissoughtisthefollowing:
{Name of GI}
IV.GEOGRAPHICALAREA
Thefollowingisthedemarcationoftheterritoryofthecountry,orregion,orlocalityinthat territory,towhichthegeographicalindicationapplies,andfromwhichthegoodsforwhichthe geographicalindicationisusedoriginate:
Additionalinformation,possiblyingraphicforms,maps, etc:
Accompanies this Form
{Please include maps, picture or anything that applicable to that GI (make it “soft-copy”)
V.GOODS:
Thegoodsforwhichthegeographicalindicationisusedarethefollowing:
Class 1 {class of good}
Wine & Spirit {example of class}
VI.DESCRIPTION OF PRODUCT

Additional information accompanies this Form
{Fill in the blank with the related information only, if not related keep it blank. Tick the additional box if the space given are not enough}
a.Colour:
b.Shape:
c.Texture:
d.Size:
e.Weight:
f.Taste:
VII.QUALITY, REPUTATION, OROTHERCHARACTERISTIC
Thequality,reputationorothercharacteristicsofthegoodsforwhichthegeographical indicationisused,andanyconditionsunderwhichtheindicationmaybeused,arethe following:

Additional information accompanies this Form
{Background of the GI, quality, reputation or other characteristic of the GI that made the GI is special than others. (make it “soft-copy) }
VIII.PROOF OF ORIGIN

Additional information accompanies this Form
{Where is the exact place of GI)
IX.CAUSAL LINK BETWEEN THE GEOGRAPHICAL AREA AND A SPECIFIC QUALITY, THE REPUTATION OR OTHER CHARACTERISTICS OF THE PRODUCT (E.G. SOIL CONDITION, CLIMATE CHARACTERISTICS, HUMAN FACTOR, PRODUCT REPUTATION)

Additional information accompanies this Form
{Factor that the GI is different from others, if not related keep it blank}
X.SPECIFIC STEPS IN PRODUCTION THAT MUST TAKE PLACE IN THE IDENTIFIED GEOGRAPHICAL AREA (E.G: SOIL PREPARATION, SELECTION AND TREATMENT OF SEED, SEED PLANTING AND FIELD MANAGEMENT (E.G. METHODS OF FERTILIZING, HARVESTING, STORING, ETC)
Additional information accompanies this Form
{Steps to produce or the method of the GI if applicable}
XI.DESCRIPTION OF LABELLING (IF ANY)
{Insert the label if any}
XII.AWARD/RECOGNITION FROM AUTHORIZED BODY (IF ANY) E.G JAKIM, SIRIM
{Insert Certificated or award or any of it}
XIII.INSPECTION BODY / AUTHORITIES OR BODIES VERIFYING COMPLIANCE WITH THE PRODUCT SPECIFICATION AND QUALITY (IF ANY)
{Anybody that verified the GI)
XIV.OTHERS (if any)
XV.FEES
accompany this Form
{RM 250.00}
XVI.DECLARATION:
Signature : ….{Producer/Competent authority/tradeorganization or association}……
Nameofsignatory(inblockletters) : {Producer/Competent authority/tradeorganization or association}
Date:……………………………………………………………………………… (Iftheapplicantis apartnership,thefullnamesofallpartnersmustbestated)
Note: / 1. / AcopyoftheStatutoryDeclarationbytheapplicantmustbeattached.
2. / AnagentsigningthisFormonbehalfoftheapplicantmustbesatisfyhimselfas to the truth of the declaration.