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APPLICANT(S)
NAME
(1)
(2)
INVENTOR (S)
NAME
NATIONALITY
ADDRESS
NATIONALITY
ADDRESS
Application
No.
Filing Date
Name of
the
Applicant
DECLARATION :
I hereby declare that to the best of my knowledge, information and belief the fact and matters
stated herein are correct and I request that a patent may be granted to me for the said
invention.
Dated this _______ day of __________ 2015
Signature: __________________
Name:
To, The Controller of Patent
The Patent Office, at Mumbai