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Form D17
Request for grounds of decision
(Regulation 28)
(Lodge in duplicate)
Date of lodgement:
Design application/registration No
Full name(s) of applicant(s):
Class(es):
Date of hearing:
I hereby request the registrar to state in writing the grounds for his decision at the above
hearing, and the facts relied upon to arrive at such decision.
Date:
_______________________________
APPLICANT/APPLICANT'S AGENT
Address for service:
FOR OFFICIAL USE ONLY
Official date
stamps
The grounds for the registrar's decision and facts relied upon are as follows/are attached: