1. 1. Trade Mark Registration Number, if any:
2. Product or Service Class (a single class only):
3. For Inclusion or substitute an address for service in Bangladesh, Applicant,
Registered Proprietor, Registered User, Opponent's:
Full Name: ........................
Address : ........................................
Nationality: ...............
Phone Number:..........................
E-mail ....................
4. Name and address of the trademark agent or lawyer appointed by the
applicant of a trade mark, registered owner, registered user and opponent:
Mr. Md. Shahid Ullah and Mr. Israqul Aman jointly and severally of Messrs.
Shahid & Alliance, Advocates of 30/3 B C Das Street, Lalbagh, Dhaka-1205,
Bangladesh
5. (A) Appointment of Trade Mark Agent or Advocate: I / we appointed my/our behalf
the person mentioned at serial number 4 to apply for registration of the trademark in
the registry or to act in all proceedings.

2. (B) Revocation of Trade Mark Agent or Advocate: I/We hereby revoke previous
authorization in respect of application for registration of a trademark and for all
other proceedings on my/our behalf
6. For alteration of service address:
Existing Address: .................................
Substituted Address : ...............................................
.................................................
Signature of the Trade Mark
Applicant/Registered Owner /
Registered user/Opponent
Dated:
To
The Registrar
Department of Patents, Designs and
..........................................
Signature of the Trade Mark
Agent/Advocate
Dated: