PCT Request {PCT-RO-101}

PCT REQUEST The undersigned requests that the present international application be processed according to the Patent Cooperation Treaty. For receiving Office use only International Application No. International Filing Date Name of receiving Office and "PCT International Application" Applicant's or agent's file reference (if desired) (12 characters maximum) Box No. I TITLE OF INVENTION Box No. II APPLICANT This person is also inventor Name and address: (Family name followed by given name; for a legal entity, full official designation. Telephone No. The address must include postal code and name of country. The country of the address indicated in this Box is the applicant's State (that is, country) of residence if no State of residence is indicated below.) Facsimile No. Applicant's registration No. with the Office E-mail authorization: Marking one of the check-boxes below authorizes the receiving Office, the International Searching Authority, the International Bureau and the International Preliminary Examining Authority to use the e-mail address indicated in this Box to send, notifications issued in respect of this international application to that e-mail address if those offices are willing to do so. exclusively in electronic form (no paper notifications will be sent). as advance copies followed by paper notifications; or E-mail address: State (that is, country) of nationality: State (that is, country) of residence: This person is applicant for the purposes of: Box No. III all designated States the States indicated in the Supplemental Box FURTHER APPLICANT(S) AND/OR (FURTHER) INVENTOR(S) Further applicants and/or (further) inventors are indicated on a continuation sheet. Box No. IV AGENT OR COMMON REPRESENTATIVE; OR ADDRESS FOR CORRESPONDENCE agent common representative The person identified below is hereby/has been appointed to act on behalf of the applicant(s) before the competent International Authorities as: The address must include postal code and name of country.) Name and address: (Family name followed by given name; for a legal entity, full official designation. Telephone No. Facsimile No. Agent's registration No. with the Office E-mail authorization: Marking one of the check-boxes below authorizes the receiving Office, the International Searching Authority, the International Bureau and the International Preliminary Examining Authority to use the e-mail address indicated in this Box to send, notifications issued in respect of this international application to that e-mail address if those offices are willing to do so. exclusively in electronic form (no paper notifications will be sent). as advance copies followed by paper notifications; or E-mail address: Address for correspondence: Mark this check-box where no agent or common representative is/has been appointed and the space above is used instead to indicate a special address to which correspondence should be sent. Form PCT/RO/101 (first sheet) (July 2015) See Notes to the request form American LegalNet, Inc. www.FormsWorkFlow.com Sheet No. . . . . . . . Box No. III FURTHER APPLICANT(S) AND/OR (FURTHER) INVENTOR(S) If none of the following sub-boxes is used, this sheet should not be included in the request. Name and address: (Family name followed by given name; for a legal entity, full official designation. This person is: The address must include postal code and name of country. The country of the address indicated in this Box is the applicant's State (that is, country) of residence if no State of residence is indicated below.) applicant only applicant and inventor inventor only (If this check-box is marked, do not fill in below.) Applicant's registration No. with the Office State (that is, country) of nationality: This person is applicant for the purposes of: all designated States State (that is, country) of residence: the States indicated in the Supplemental Box Name and address: (Family name followed by given name; for a legal entity, full official designation. This person is: The address must include postal code and name of country. The country of the address indicated in this Box is the applicant's State (that is, country) of residence if no State of residence is indicated below.) applicant only applicant and inventor inventor only (If this check-box is marked, do not fill in below.) Applicant's registration No. with the Office State (that is, country) of nationality: This person is applicant for the purposes of: all designated States State (that is, country) of residence: the States indicated in the Supplemental Box Name and address: (Family name followed by given name; for a legal entity, full official designation. This person is: The address must include postal code and name of country. The country of the address indicated in this Box is the applicant's State (that is, country) of residence if no State of residence is indicated below.) applicant only applicant and inventor inventor only (If this check-box is marked, do not fill in below.) Applicant's registration No. with the Office State (that is, country) of nationality: This person is applicant for the purposes of: all designated States State (that is, country) of residence: the States indicated in the Supplemental Box Name and address: (Family name followed by given name; for a legal entity, full official designation. This person is: The address must include postal code and name of country. The country of the address indicated in this Box is the applicant's State (that is, country) of residence if no State of residence is indicated below.) applicant only applicant and inventor inventor only (If this check-box is marked, do not fill in below.) Applicant's registration No. with the Office State (that is, country) of nationality: This person is applicant for the purposes of: all designated States State (that is, country) of residence: the States indicated in the Supplemental Box Further applicants and/or (further) inventors are indicated on another continuation sheet. Form PCT/RO/101 (continuation sheet) (July 2015) See Notes to the request form American LegalNet, Inc. www.FormsWorkFlow.com Sheet No. . . . . . . . Supplemental Box If the Supplemental Box is not used, this sheet should not be included in the request. 1. (i) (ii) (iii) (iv) (v) If, in any of the Boxes, except Boxes Nos. VIII(i) to (v) for which a special continuation box is provided, the space is insufficient to furnish all the information: in such case, write "Continuation of Box No...." (indi