SINGAPORE PATENTS ACT (CHAPTER 221)
PATENTS RULESPATENTS FORM 12A

Request for Supplementary Examination Report

Estimated Time:
This form may take approximately 8 - 12 minutes to complete.
General:a. * denotes mandatory fields.
b. Attention is drawn to sections 104 and 105 of the Patents Act, rules 90 and 105 of the Patents Rules, and the Patents(Patent Agents) Rules 2001.

PART 1

Reference
Applicant/ Agent
Reference

PART 2

Application No.*
Application No.*PART 3Name of Applicant*Note: If there is insufficient space, please use the continuation sheet CS 4.

UEN/ Company Code(if applicable)

Name

Sole Proprietor orPartners' Name
(if sole proprietorship orpartnership)

PART 4Prescribed Document Furnished*

Prescribed DocumentFurnished(Note:Cross only one option
and any supporting options
where required. A claim
correspondence table must befurnished.)

You are relying on the final results of a corresponding
application, corresponding international application or related
national phase application (details to be provided below)
A certified copy of granted patent or a copy thereof: orDocument(s) setting out the final results of the searchand examination as to substance with a copy of claims
referred to in the final results.

You are relying on the final results of any search andexamination as to the substance of the application in suitduring its international phase (details to be provided below)
You are relying on an International Preliminary Reporton Patentability (Chap 1)
Page 1 of 4(i)Application/ patent no.
of the corresponding
applicationorthecorresponding
international application(ii)

Filedinor

under(Prescribedpatentoffice/Patent Co-operation Treaty)

Yes

PCT Article 19 and/or
34 amendments weremade (to indicate forcorresponding
international applicationonly)No

You are relying on the final results of any search andexamination as to the substance of the application in suitduring its international phase (details to be provided below)
You are relying on an International Preliminary reporton Patentability (Chap 1)
PCT Article 19
amendments were made

Yes

No

You are relying on an International Preliminary Reporton Patentability (Chap 2)
PCT Article 19 and/or 34
amendments were madeX

Yes

No

Page 2 of 4

PART 5International Patent Classification (IPC)*

Note: If there is insufficient space, please use the continuation sheet in CS 6.

International PatentClassification (IPC) for
the Application*

PART 6

Contact Details*

Note:a. Where an agent with UEN is appointed, the fields for "Agent UEN/ Company Code", "Agent Name" and "Address forService in Singapore" should be completed. Where an individual or an agent without UEN is appointed, the sub-field“Representative or C/O Name” and "Address for Service in Singapore" should be completed instead.
b. The official correspondence will be sent to the address for service in Singapore as indicated in this box, and must be thesame as the one on our record.
c. Please file Form CM1 if you are a different agent or Form CM2 if you have changed your address for service in Singapore.

Agent UEN/ Company
CodeAgent Name

Representative or C/O
Name
Address for Service in Singapore
Block/ House
No.
Street Name
Level - Unit-

Building
Name
Postal CodeContact Person(if applicable)

Direct Telephone No.
(if applicable)

Email Address(if applicable)

Page 3 of 4

PART 7

Declaration*
Declaration

By Person Filing the FormI, the undersigned, do hereby declare that the information furnishedabove is true to the best of my knowledge. I understand that I may beliable for criminal prosecution for providing any false information in thisapplication.
By AgentI, the undersigned, do hereby declare that:i.

I have been duly authorised to act as an agent on behalf of theperson(s) filing this form.

ii.

The information furnished above on behalf of the person(s) filingthis form is true to the best of the person(s)' knowledge. I
understand that I may be liable for criminal prosecution forproviding any false information in this application.

Name
SignatureDate(DD/MM/YYYY)

No. of Extra Sheets
Attached to this Form

sheet(s)Page 4 of 4