Dated at ………………… this ……….. day of ………….. 20 ……… Signature(s) ……………………… Applicant(s) NOTES: 1. Please use a separate form for each document requested. 2. This form may be used to obtain certified copies of documents or extracts. 3. Please describe any special requirements. If the space provided is not sufficient, please use a separate sheet of paper. FORM NO CR 23 (r. 22 (2)) THE COPYRIGHT ACT, 2001 The Kenya Copyright Board REQUEST FOR A COPY OF A LOST OR DESTROYED CERTIFICATE Applicant’s/agent’s reference Name and address of applicant Physical address of applicant Name and address of the agent (if any) The registration number of the certificate Title of the certificate a copy of which is required Description of the certificate I/We, the above identified applicant(s), hereby apply for a copy of the above quoted certificate that has been lost or destroyed. The statutory declaration or affidavit required under Regulation 22 (3) is attached. Dated at ………………. this ………… day of ……………, 20 ……… Signature(s) …………………… Applicant(s)