FORM NO. 2A
APPLICATION FOR AN ADDRESS FOR SERVICE

1. I/We

2. Patent No.

3. Apply for entry of

Date

4. Signature

Email (required)

The Registrar
Intellectual Property Office
BELIZE

--------------------------------------------------------------------------------------------------------------------------------------------------------------------

  1. Name of patentee or registered licensee(s).
  2. Identify Patent.
  3. State address for service.
  4. The application may be signed by printing, completing and faxing or attaching the FACSIMILE SIGNATURE FORM, or using any combination of letters, numbers, spaces or punctuation marks placed between two forward slash ("/") symbols. Examples of acceptable password signatures for electronic application forms include /ramses/, /drl/, and /577-34567/ (Section 9 of CAP. 290:01 read with Paragraph 2 of A.I. No. 5 of 2005). An applicant must notify the Office of his particular method of electronic signature.