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NOTICE OF ALLEGED INFRINGEMENT FORM


CONTACT INFORMATION:
 
Your Name:                __________________________________________
 
Your Title:                   __________________________________________
 
Are you a member of molmed.org? ?    [  ]  Yes or   [  ] No
 
If Yes, please provide your member name: _________________________
 
Company Name:         __________________________________________
 
Address:                      __________________________________________
 
City:                            __________________________________________
 
State:               ______
 
Country:          ______
 
eMail:              ________________________________________________
 
Additional eMail: _____________________________________________
 
Phone:             ________________________________________________
 
Additional Phone: _____________________________________________
 
Fax:                 _______________________
 
Are you the rights holder?    [  ]  Yes or   [  ] No
 
Do you represent the rights holder?   [   ]  Yes or [  ]  No
 
            If yes:   In what capacity do you represent the rights holder:  ____________________
 
 
IDENTIFICATION OF OBJECTIONABLE CONTENT:
 
URL:   ________________________
 
Description of Text:    ________________________
 
Nature of Objection:   _________________________________________________
(Please note that the more detailed an explanation of the nature of the objection the better we will be able to potentially address your concern).
 
[   ]  Additional Objectionable Content
(If more than one instance, please check box and identify additional objectionable content)
 
 
 
IDENTIFICATION OF INTELLECTUAL PROPERTY RIGHTS
 
[    ] Copyright                        Country of Registration: ____________        Reg. No. __________ 
            [   ] Click here to upload a copy of your registration
            Comment:   _________________________________________________
 
I have a good faith belief that the use of the copyrighted materials described above as objectionable content is not authorized by the copyright owner, its agent, or the law.
[   ]   I agree                [    ]  I disagree
 
            [   ] Additional Copyrights
            (If more than one instance, please check box and complete information for each additional copyright)
 
 
[    ]  Trademark          Country of Registration:  ____________       Reg. No. __________
            [   ] Click here to upload a copy of your registration
            Comment:   _________________________________________________
 
I have a good faith belief that the use of the trademarked materials described above as objectionable content is not authorized by the trademark owner, its agent, or the law.
[   ]   I agree                [    ]  I disagree
 
 
            [   ] Additional Trademarks
            (If more than one instance, please check box and complete information for each additional trademark)
 
[   ]    Other
            Comment:   _________________________________________________
 
VERIFICATION
 
I hereby swear under penalty of perjury, that the information in this notification is complete and accurate and I am the rights owner or authorized to act on behalf of the owner or of an exclusive right that is allegedly infringed.
 
            [   ]  I agree                 [   ]  I disagree
 
 
I hereby consent to the jurisdiction of the U.S. District Court for the Eastern District of New York, and I will accept service of process for purposes of any dispute arising out of the submission of this Notice.
 
SIGNATURE
 
Signed on this date of  ______/______/______
                                    Month   Day      Year
 
Signature:        _____________________________
 
Your digital signature is as legally binding as a physical signature
 
[   ]  Check here if you would like a copy of this notice as submitted e-mailed to you.  The e-mail will include a notification number which should be referred to in all future correspondence.