IPIN/IINGA/T/2 Page 59 FORM 12 TRADE MARKS ACT (FEE STAMP-ITEMS II, II a or lIb) Renewal oj Registration oj Trade Mark (Regulation 66) (a) I, (or We), . of . hereby leave the prescribed fee of for Renewal of Registration of the Trade Mark No. . in Class . "which I am directed by the proprietor of the Trade Mark, that is to say by (b) , to pay.* DATED this day of ,19 . (c) (d) . . The Statement on the back oj this Form must be jiffed in, and signed. To: The Registrar of Trade Marks, Federal Ministry of Trade and Tourism, Abuja, Nigeria. *This Form will be returned if it is filed more than three months before the expiration of the last registration. (To appear on back oj the Form) The Registrar is requested to send notice of renewal of the Registration to (e) the Registered Proprietor at the following address: (J) DATED this day of 19 . Insert here the name and address of the person leaving the fcc. **Ifthe fee is left by the proprietor himself, this passage should be struck out. (b) If the fee is not left by the proprietor himself, insert his name and address here. (c) Signature of the person leaving the fee. (d) Address of the person signing. (e) If the request is signed by the Registered Proprietor strike out here the words "the Registered Proprietor" and substitute the word " me '" . (J) Signature. (a)