INDIVIDUAL APPLICATION

PRINCIPAL REGISTER WITH DECLARATION

 

 

Mark:  _____________________________________

 

Class Number:  _______________________________

 

 

TO THE COMMISSIONER OF PATENTS AND TRADEMARKS:

 

_______________________________________________________ (Name of Applicant)

 

________________________________________________ (Business Name and Address)

 

_______________________________________________________ (Residence Address)

 

___________________________________________________ (Citizenship of Applicant)

 

The above identified applicant has adopted and is using the trademark shown in the accompanying drawing for __________ (Common, Usual or Ordinary Name of Goods) and requests that such mark be registered in the United States Patent and Trademark Office on the Principal Register established by the Act of July 5, 1946.  

 

The trademark was first used on the goods on __________ (Date); was first used in _____________________________________________ (Type of Commerce) commerce on _______________ (date); and is now in use in such commerce.

 

The mark is used by applying it to ____________________________________________ (Manner of Application, such as the goods or labels affixed to the Product).  Five samples showing the mark as actually used are presented herewith.  

 

DECLARATION 

 

_______________________________________________________ (Name of applicant), being hereby 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:  

 

1.  __________ (he or she) believes __________ (himself or herself) to be the owner of the trademark sought to be registered; 

 

2.  To the best of (his or her) knowledge and belief no other person, firm, corporation or association has the right to use the mark in commerce, either in the identical form or in such near resemblance thereto as may be likely, when applied to the goods of such other person to cause confusion, or to cause mistake, or to deceive; 

 

3.  The facts set forth in this application are true; 

 

4.  All statements made in this application of (his or her) own knowledge are true and all statements made on information and belief are believed to be true; and 

 

5.  These statements were made with the knowledge 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 document or any registration resulting therefrom.

 

Dated:  __________

 

 

 

___________________________________                       ______________

Signature of applicant                                                 Date

 

Attach designation of domestic representative, if necessary.