:ns R.EGISTRAR'S OFFICE, LESOTHO Form No.4 (Reg.31 (I) ) INDUSTRIAL PROPERTY ORDER REQUEST FOR GRANT OF NON-VOLUNTARY LICENCE ON GROUNDS OF NON-WORKING OR INSUFFICIENT WORKING To: The Registrar Registrar's Office P.O. Box 33 Maseru lOa 1. Application received on: Fee received on: Date of mailing: Applicant's or agent's file reference IN THE MATTER OF: D D II. For Official Use Patent No.: Date of Grant: Utility Model Certificate No.: APPLICANT Name: Address: Address for service in Lesotho: Nationality: Country of residenoe or principal place of business: Telephone No.: III. Telegraphic Address: Telex No.: REQUEST The above appl icant hereby requests the Registrar, in respect of the patent/utility model certificate, * identified above to grant a non-voluntary licence under section 15 of the Industrial Property Order. 1989. in accordance with the terms proposed and upon the grounds set out below. IV. PROPOSED TERMS Amount and conditions of payment of remuneration: Conditions of exploitation of invention: Others: V. FACTS JUSTIFYING GRANT * Delete whichever does not apply. (Form No.4 first page)