Dated at ………………… this ……….. day of ………….. 20 ………
Signature(s) ………………………
Applicant(s)
NOTES:
1. Please use a separate form for each document requested.
2. This form may be used to obtain certified copies of documents or extracts.
3. Please describe any special requirements. If the space provided is not sufficient, please
use a separate sheet of paper.
FORM NO CR 23 (r. 22 (2))
THE COPYRIGHT ACT, 2001
The Kenya Copyright Board
REQUEST FOR A COPY OF A LOST OR DESTROYED CERTIFICATE
Applicant’s/agent’s reference
Name and address of applicant
Physical address of applicant
Name and address of the agent (if any)
The registration number of the certificate
Title of the certificate a copy of which is
required
Description of the certificate
I/We, the above identified applicant(s), hereby apply for a copy of the above quoted
certificate that has been lost or destroyed.
The statutory declaration or affidavit required under Regulation 22 (3) is attached.
Dated at ………………. this ………… day of ……………, 20 ………
Signature(s) ……………………
Applicant(s)