Form D.T. No. 4 Section 21 Rule 11 (1) THE REGISTERED DESIGNS ACT Fee units: 12 REFERENCE TO THE TRIBUNAL UNDER SECTION 21 OF THE ACT IN THE MATTER of a reference by (1) (1) State the name of claimant(s) and nature of matter in dispute against (2) (2) State name of other party to dispute I/We (3) (3) State full name and address of claimant(s) hereby refer for the determination of the Tribunal my/our claim against (4) (4) State full name of respondent The following are the grounds on which I/we base my/our claim: (5) Dated this (5) Here state briefly the nature of the grounds day of .........................................., 19 .............