FORMULIR PERMOHONAN PENDAFTARAN MEREK INDONESIA

APPLICATION FORM OF INDONESIAN TRADEMARK REGISTRATION

Data Permohonan (Application)

Nomor Transaksi : IPT2023107710 Asal Permohonan : Online Filing
Number of Transaction Office of Origin
Nomor Permohonan : IPT2023107710 Tipe Permohonan : Merek Jasa
Number of Application Type of Application
Tanggal Penerimaan : 2023-06-22 11:30:10 Jenis Permohonan : Umum
Receipt Date Sub Type of Application

Data Merek (Description of Mark)

Tipe Merek : Merek Kata dan Lukisan Etiket Gambar/Label Merek
Type of Mark Image of Mark
Nama Merek : HOLY KUMALA FISIOTERAPI
Name of Mark

Deskripsi : Struktur tulang punggung manusia, daun dan tulisan HK

Description Fisioterapi

Warna : Hitam, Putih

Colors

Terjemahan : Tidak Ada Terjemahan

Translation

Transliterasi/Pengucapan :
Transliteration

Disclaimers :
Disclaimers

Data Pemohon (Applicant)

Signed by IPROLINE Merek

on 2023/06/22 14:07:18
Nama : HOLY CHRISTY KUMALA HENRYANTO
Name
Jenis Pemohon : Perorangan
Owner Type
Kewarganegaraan : Indonesia
Nationality
Alamat : Jl. Bedugul BLK B/9 LK2 RT 002/RW 000, Kel. Way Halim Permai, Kec. Way Halim, Kota Bandar
Lampung, 35141
Address

Kabupaten/Kota : Kota Bandar Lampung Kode Pos : 35141

City Zip Code
Provinsi : Lampung Negara : Indonesia
Province Country
Telepon : 081297346725
Phone
Surel : holychristykumala@gmail.com
Email

Alamat Surat Menyurat (Mailing Address)

Alamat :
Address

Kabupaten/Kota : Kode Pos :

City Zip Code
Provinsi : Negara :
Province Country
Telp/Fax :
Phone
Surel :
Email

Data Kuasa (Representative/IP Consultant)

Nama Konsultan : No Konsultan :
Consultant Name Number of Consultant
Nama Kantor :
Office Name
Alamat :
Address

Telp/Fax :
Phone
Surel :
Email

Data Prioritas (Priority Data)

Tanggal Prioritas Negara / Kantor Merek No Prioritas

No
(Priority Date) (Priority Country) (Number of Priority)
Data Kelas (Class)

Kelas Uraian Barang dan/atau Jasa

(Class) (Description of Goods/Services)
44 Jasa fisioterapi; chiropractic, fisioterapi, akupunktur, osteopati, kedokteran olahraga, pijat dan layanan
paramedis; fisioterapi [terapi fisik]

-; chiropractic, physiotherapy, acupuncture, osteopathy, sports medicine, massage and paramedical

services; physiotherapy [physical therapy]

Dokumen Lampiran (Attachment)

Tanda Tangan Digital Pemohon

Identitas pemohon jika pemohon lebih dari satu pihak (Additional Applicant)

No Nama Pemohon Tambahan

Gambar Merek Tambahan (Additional Mark)

No Gambar Merek Tambahan

Tanda Tangan Pemohon / Kuasa (Applicant / Representative Signature)

(HOLY CHRISTY KUMALA HENRYANTO)

Tempat dan Tanggal (Place and Date) : Jakarta, 22-06-2023