| I ................................................................................................................... given notice that |
| Full name of signatory in BLOCK LETTERS |
| ..................................................................................................................... |
| Name and address of Owner of Copyright |
| ..................................................................................................................... |
| is the owner of the copyright in the work, film or sound recording specified below which subsists under the Copyright Act and I request that any infringing copies of the said work, film or sound recording be treated as prohibited goods for a period starting on ................................. and ending on .................................... |