Information on the merchandise suspected of being counterfeit or pirated: - Nature of the merchandise: - Commercial designation: - Origin: 3 - From:3 - Distinctive elements making it possible to identify the merchandise suspected of being counterfeit or pirated: 4 - Country of production:3 - Name and address of manufacturer:3 - Other useful information:3 - Quantity Attachments: - Undertaking: - Other documents: Done at , (Stamp and signature) 3 4 If such information is available. Attach documents, such as catalogs, photos, brochures. 8