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In Connection with :

 of
 to

Act as my (or our) Agent and to receive all notices, requisitions and communications until Further notice. And I (or We) revoke the previous authority given by me in the matter.

Dated :
     (MM / DD / YYYY)

Day Of :
 2008

 

__________________
(Authorized Signature)

To,
The Controller of Design
The Patent Office,
CALCUTTA.

 

  

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