The Laws of Zambia 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) Stat name o claiman and na matter dispute against (2) ................................................................................................................................................................................................ (2) Stat of othe .................................................................................................................................................................................................... to dispu I/We (3) .............................................................................................................................................................................. (3) Stat name a addres claiman .................................................................................................................................................................................................... hereby refer for the determination of the Tribunal my/our claim against (4) .............................................................................. (4) Stat name o respon .................................................................................................................................................................................................... The following are the grounds on which I/we base my/our claim: (5) ................................................................................................................................................................................................ (5) Her briefly t .................................................................................................................................................................................................... nature .................................................................................................................................................................................................... ground .................................................................................................................................................................................................... .................................................................................................................................................................................................... Dated this ................................................................................................day of .........................................., 19 ............. (6) .............................................................................................. .................................................................................................... My/Our address for service in Zambia: .................................................................................................................................................................................... .................................................................................................................................................................................... .................................................................................................................................................................................... The Registrar, The Designs Office, Lusaka, Zambia. NOTE-The claim must be accompanied by an affidavit verifying the facts and stating fully the nature of the interest in the matter in dispute and the relief sought. Copyright Ministry of Legal Affairs, Government of the Republic of Zambia (6) To b signed claiman his/thei practitio