Name of the Applicant:

Business Address:

Country of citizenship (individual):

State of Incorporation or Country of organization (partnership, corporation):

Mark (if a word mark):

Attach JPG image if design mark :

Any color claimed?

Specific Goods or Services :

Date of first use goods or services anywhere:

Date of first use of goods or services in the U.S. or with the U.S.:

Attach JPG image of the specimen on which mark is used:

(a) If you do not have a JPG image then mail/fax a copy of a label, tag, instruction manuals, package or point of sale display showing the mark as used.

Country of Origin Application:

To file an application in the U.S. trademark office on the basis of a country of origin application, the U.S. application must have the same owner, the same mark and the same or narrower goods/services as the country of origin application.

Country:

Application Number:

Application Date:

Description of Goods or Services:

Class of Goods or Services:

Does Applicant have a bona fide intention to use the mark in the U.S.?

Country of Origin Registration:

To file an application in the U.S. trademark office on the basis of a country of origin registration, the U.S. application must have the same owner, the same mark and the same or narrower goods/services as the country of origin registration.

Country:

Registration Number:

Registration Date:

Goods or Services:

Class of Goods or Services:

Does Applicant have a bona fide intention to use the mark in the U.S.?

Your Contact Information:

Name of individual:

Name of firm or company:

Address:

Telephone:

Fax:

Email: