PCT

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Box No. IIAPPLICANTBox No. ITITLE OF INVENTIONPCTThe undersigned requests that the presentinternational application be processedaccording to the Patent Cooperation s or agent s file reference(if desired) (12 characters maximum)For receiving Office use onlyInternational Application Filing DateName of receiving Office and PCT International Application Name and address:(Family name followed by given name; for a legal entity, full official address must include postal code and name of country. The country of the address indicated in thisBox is the applicant s State (that is, country) of residence if no State of residence is indicated below.)This person is also inventorThis person is applicantfor the purposes of:all designated Statesthe States indicated in the Supplemental BoxState (that is, country) of residence :State (that is, country) of nationality:Box No. IIIFURTHER APPLICANT(S) AND/OR (FURTHER) INVENTOR(S)Box No. IVAGENT OR COMMON REPRESENTATIVE; OR ADDRESS FOR CORRESPONDENCEThe person identified below is hereby/has been appointed to act on behalfof the applicant(s) before the competent International Authorities as:Name and address:Further applicants and/or (further) inventors are indicated on a continuation (Family name followed by given name; for a legal entity, full official address must include postal code and name of country.)

Form PCT/RO/101 (continuation sheet) (July 2017) See Notes to the request form State (that is, country) of nationality: State (that is, country) of residence: State (that is, country) of nationality: State (that is, country) of residence:

  Residence, Of residence