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TRANSLATION

Form of a Petition for the Grant of a Patent. Form of petition for the

grant of a patent.

Worshipful, or Most Worshipful

{The name of the political district, county, or delegational authority, or provincial Government, to whom application is made, is to he stated here.')

I {we), N. N. {Christian and Surname, business aud residence of the applicant or applicants for the patent) herewith announce in due form, that I {we) have made a new discovery {invention, improvement), which in effect consists of {The representation of it has to follow here).

The accurate specification thereof, drawn up in accordance with the provision contained in § 12 of the Imperial ordinance of August 15, 1852, is enclosed herewith.

{If the applicant for a petition desires the specification to be kept secret, he must state this, and if drawings, models, patterns, Sfc. are appended at same time, the number of them must be accurately given.)

This discovery ( invention, improvement), announced and described in due form, which I {we), the undersigned applicant {applicants) for a patent deem to be lawfully suitable for such, and to be new according to the provisions of the Imperial ordinance aforesaid to the best of my {our) knowledge, and consequently at my {our) own risk, and on my {our) own responsibility deem to be lawfully suitable for the obtainment of a sole patent, I {we) therefore apply herewith for such patent for the discovery {invention, improvement) announced, in the manner shown in the enclosed sealed specification, subject to the legal conditions and stipulations, for years, for which purpose the tariff for the grant of a patent, payable

in accordance with § 11 of the aforesaid Imperial ordinance, is hereby declared to be entirely paid by me {us) in the sum of florins, and the issue of an official

certificate in order to secure the priority of my {our) claims is therefore requested.

{Place, and date of application.)

{Signature{s).

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