APPLICATION FOR REGISTRATION OF:

Trademark_____    Trade name_____    Service mark_____

Applicant's name  ____________________________________________________

On behalf of (business name)  ____________________________________________________

I have authorization to act on behalf of the above-named business.

Yes_____   No_____

Official title:  ____________________________________________________

Applicant is a: Sole proprietorship_____  Partnership_____

Corporation_____  Limited liability company_____  Other_________________________

If applicant is a sole proprietorship, are you a U. S. citizen?   Yes_____  No_____

If applicant is a corporation, state of incorporation:  _______________________

Applicant's business address:  

____________________________________________________

____________________________________________________

Applicant's business telephone number, including area code:  _______________

Applicant's business fax number:  _______________________________________

Applicant's business e-mail address:  _____________________________________

Application is for: Federal registration only_____   State registration only_____   Both_____

State(s) in which registration is desired  ______________________________________

Is registration outside of the United States desired?   Yes_____No_____

If so, in what other countries?

____________________________________________________

____________________________________________________

Date the name or mark began/will be in use:  ____________________________

The name or mark will be used to identify (check all that apply):

A business organization_____   Goods_____   Services_____

Registration is for (check all that apply):

Word(s) only_____   Word(s) in special lettering_____   Logo or design_____

Word(s) and logo_____

Company name_____   Domain name_____

Print, type, or attach the exact name or mark here.

The name or mark relates to the following type of business, product(s), or service(s):

____________________________________________________

____________________________________________________

Research conducted to date included the following resources:

____________________________________________________

____________________________________________________

Results of that research:

____________________________________________________

____________________________________________________

I have personal knowledge that all of the above information is true, complete, and accurate.

_____________________________       Date:__________________
Signature of applicant

On behalf of ___________________________