Descrizione dell’invenzione industriale dal titolo _________________________

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a nome di (o della ditta) ___________________________________________

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di nazionalità____________________residente (o con sede ) in____________

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via_________________________________________________ n__________

inventore designato:______________________________________________

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depositata il_______________________n_____________________________

DESCRIZIONE

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RIVENDICAZIONI

(su foglio a parte)

1)_____________________________________________________________

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2)_____________________________________________________________

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Data ___/___/200__

Firma del richiedente_______________________