Report Infringement/Counterfeit Form

Intellectual Property (IP) Infringement/Counterfeit Report Form

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1. Reporter Information:

Your Name(Required)

First Last

Company (if applicable)

Phone Number(Required)

Email Address(Required)

2. Relationship to the Rights Holder:

(Please tick the appropriate box)

Rights(Required)

I am the intellectual property owner.

I am an authorised representative of the intellectual property owner.

I am a third party reporting suspected counterfeit/infringement.

3. Intellectual Property Details:

Type of Intellectual Property(Required)

Trademark

Patent

Design

Other

Other (please specify)

Intellectual Property Registration Number (if applicable)

Jurisdiction(s) where the IP is registered (if applicable):

4. Allegedly Infringing Product/Item Information:

Platform/Seller Name(Required)

Product Name/Description(Required)

Listing ID or URL(Required)

Description of the Infringement or Counterfeit Claim(Required)

(Please provide details of why you believe this product/item infringes on your intellectual property or is counterfeit.)

Supporting Documents

Max. file size: 6 GB.

If applicable, attach any documents that support your claim, such as proof of registration, images of the authentic product, or evidence of infringement.)

5. Declaration

I, the undersigned, declare that the information provided in this report is accurate to the best of my knowledge and that I have the authority to act on behalf of the intellectual property owner if applicable.

Name(Required)

First Last

Signature(Required)

Date(Required)

6. Contact for Follow-Up

If necessary, please provide a preferred method of contact for follow-up on this report:

Your Phone(Required)

Your Email Address(Required)