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FORM D4
(Lodge in duplicate) REPUBLIC OF SOUTH AFRICA
DESIGNS ACT, 1993

APPLICATION OR REQUEST TO THE REGISTRAR

(Regulation 24)

Official application No.: Date of lodgement:

Full name(s) of applicant(s):

.

In terms of the following sections and/or regulations:

(a) section
(b) regulation
the applicant hereby requests the following:

Documents, if any, lodged in support of the request:

Date:

APPLICANT/APPLICANT'S AGENT

Address for service:

FOR OFFICIAL USE ONLY

The above application or request is hereby allowed/refused.

Official date stamp
Reasons for refusal of conditions of allowance, if any:

Registrar of Designs