Blank Form Conservatorship

IN THE UNITED STATES PATENT AND TRADEMARK OFFICE

APPLICATION FOR REGISTRATION OF MARK

PRINCIPAL REGISTER

Mark: _______________

Mark in all Caps

Int’l Class No(s).:_____________

Applicant:_______________________________________

A Corporation of the State of _______________________

Business Address: ______________________________

______________________________

STATEMENT

Applicant has adopted and is using the mark in commerce as shown in the accompanying drawing for the following goods and/or services: ______________________________________________________________________________________ (Description of Goods/Services in all Caps) in International Class(es) _______________, and requests that said mark be registered in the United States Patent and Trademark Office on the Principal Register established by the Act of July 5, 1946 (15 USC § 1051 et seq., as amended). The mark was first used on or in connection with the goods services on or about ___________________ (First Date of Use), was first used in interstate commerce on or about ____________________ (First Date of Use), and is now in use in such commerce.

The mark is used by applying it to (Check all that apply and repeat for each class.):

[ ] the goods

[ ] labels which are affixed to the goods

[ ] packages in which the goods are sold

[ ] literature accompanying the goods

[ ] point-of-sale display material for the goods

        [     ] promotional material related to the services and uttering it in the course of rendering the services and in other
                     ways customary in the trade; and
             [     ] three specimens
             [     ] facsimiles showing the mark as used in commerce are enclosed with this application.

Applicant is the owner of Registration No(s). ___________________________________

This is not a substitute for legal advice. An attorney must be consulted.
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DECLARATION AND POWER OF ATTORNEY

The undersigned, being warned that willful false statements and the like so made are punishable by fine or imprisonment, or both, under Section 1001 of Title 18 of the United States Code and that such willful false statements may jeopardize the validity of the application or any registration resulting therefrom, declares that: I am ______________________________ (Title) of Applicant and am authorized to execute this instrument on behalf of the Applicant; I believe the Applicant to be the owner of the mark sought to be registered; to the best of my knowledge and belief no other person, firm, corporation, or association has the right to use such mark in commerce, either in the identical form or in such near resemblance thereto as to be likely, when used on or in connection with the goods or services of such other person, to cause confusion, or to cause mistake, or to deceive; and all statements made on my knowledge are true and all statements made on information and belief are believed to be true.

Applicant appoints _______________________________________________________________________________________ (List Attorneys’ Names) of the Bar of the State of __________________________________________, whose addresses are ______________________________________________________________________________________, telephone number (___)____________, to prosecute this application to register, to transact all business in the Patent and Trademark Office in connection therewith, and to receive the Certificate of Registration.

Please correspond with:

______________________________

___________________________________________

Applicant’s Name

By:_________________________________________ Date: ______________________

Signature

_________________________________________
Name and Title

Name of Applicant: _____________________________

Address:______________________________________

_____________________________________

For:__________________________________________

Place Drawing or Typed Mark Here