Wniosek PCT

For receiving Office use only

PCT

International Application No. PCT/EP2023/012345

REQUEST

International Filing Date 2023-10-27

The undersigned requests that the present

international application be processed

according to the Patent Cooperation Treaty.

Name of receiving Office and “PCT International Application”

Applicant’s or agent’s file reference

(if desired) (12 characters maximum) APP-2023-OCT

Box No. I TITLE OF INVENTION Improved Widget Design

Box No. II APPLICANT This person is also inventor

Name and address: (Family name followed by given name; for a legal entity, full official designation. Telephone No.

The address must include postal code and name of country. The country of the address indicated in this

Box is the applicant’s State (that is, country) of residence if no State of residence is indicated below.)

Jan Kowalski / Widget Innovations Inc.

ul. Kwiatowa 12, 00-001 Warszawa, Polska

+48 123 456 789

Facsimile No. +48 123 456 789

Teleprinter No. +48 123 456 789

Applicant’s registration No. with the Office PL123456

State (that is, country) of nationality: Polska

State (that is, country) of residence: Polska

This person is applicant all designated all designated States except the United States the States indicated in

for the purposes of: States the United States of America of America only the Supplemental Box

Box No. III FURTHER APPLICANT(S) AND/OR (FURTHER) INVENTOR(S)

Name and address: (Family name followed by given name; for a legal entity, full official designation.

The address must include postal code and name of country. The country of the address indicated in this This person is:

Box is the applicant’s State (that is, country) of residence if no State of residence is indicated below.)

Anna Nowak / Widget Innovations Inc.

ul. Słoneczna 23, 00-002 Warszawa, Polska applicant only

applicant and inventor

inventor only (If this check-box is

marked, do not fill in below.)

Applicant’s registration No. with the Office PL654321

State (that is, country) of nationality: Polska

State (that is, country) of residence: Polska

This person is applicant all designated all designated States except the United States the States indicated in

for the purposes of: States the United States of America of America only the Supplemental Box

Further applicants and/or (further) inventors are indicated on a continuation sheet.

Box No. IV AGENT OR COMMON REPRESENTATIVE; OR ADDRESS FOR CORRESPONDENCE

The person identified below is hereby/has been appointed to act on behalf agent common

of the applicant(s) before the competent International Authorities as: representative

Name and address: (Family name followed by given name; for a legal entity, full official designation. Telephone No.

The address must include postal code and name of country.)

Piotr Wiśniewski / Legal Experts Ltd.

ul. Mokotowska 45, 00-003 Warszawa, Polska

+48 987 654 321

Facsimile No. +48 987 654 321

Teleprinter No. +48 987 654 321

Agent’s registration No. with the Office AG789012

Address for correspondence: Mark this check-box where no agent or common representative is/has been appointed and the

space above is used instead to indicate a special address to which correspondence should be sent.

Form PCT/RO/101 (first sheet) (April 2006) See Notes to the request form

Sheet No. 2

Continuation of Box No. III FURTHER APPLICANT(S) AND/OR (FURTHER) INVENTOR(S)

If none of the following sub-boxes is used, this sheet should not be included in the request.

Name and address: (Family name followed by given name; for a legal entity, full official designation. This person is:

The address must include postal code and name of country. The country of the address indicated in this

Box is the applicant’s State (that is, country) of residence if no State of residence is indicated below.)

Tomasz Malinowski / Widget Innovations Inc.

ul. Lipowa 56, 00-004 Warszawa, Polska applicant only

applicant and inventor

inventor only (If this check-box

is marked, do not fill in below.)

Applicant’s registration No. with the Office PL246801

State (that is, country) of nationality: Polska

State (that is, country) of residence: Polska

This person is applicant all designated all designated States except the United States the States indicated in

for the purposes of: States the United States of America of America only the Supplemental Box

Name and address: (Family name followed by given name; for a legal entity, full official designation. This person is:

The address must include postal code and name of country. The country of the address indicated in this

Box is the applicant’s State (that is, country) of residence if no State of residence is indicated below.)

Katarzyna Zielińska / Widget Innovations Inc.

ul. Brzozowa 78, 00-005 Warszawa, Polska applicant only

applicant and inventor

inventor only (If this check-box