SERVICE
MARK APPLICATION
PRINCIPAL
REGISTER--WITH DECLARATION
REGISTRATION
OF SERVICE MARK IN THE UNITED STATES PATENT AND TRADEMARK OFFICE
Mark: ____________________________________
Class
Number: _____________________________
TO
THE COMMISSIONER OF PATENTS AND TRADEMARKS:
(Insert
appropriate identification of applicant)
The
above identified applicant has adopted and is using the service mark shown in
the accompanying drawing for ___________________________________ (Common, Usual
or Ordinary Name of Service) 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
service mark was first used in connection with the services on __________
(Date); was first used in connection with the services rendered in
__________________________ (Type of Commerce) commerce on __________ (Date);
and is now in use in such commerce.
The
mark is used by __________________________________ (State Method of Using the
Mark in Connection with the Services), and five _________________________
(Specimens or State Nature of Furnished Representation of Mark) showing the
mark as actually used are presented herewith.
DECLARATION
Insert
appropriate declaration from those set forth below:
If
applicant is an individual, state:
_____________________________________________________
(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 service mark 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 services 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;
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.
___________________________________ _______________
Signature
of Applicant Date
If
applicant is a partnership, state:
_____________________________________
(Name of Partner), 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 validity of the application or any registration resulting therefrom,
declares that:
1. __________ (He or She) is a partner of
applicant partnership;
2. __________ (He or She) believes such
partnership to be the owner of the service mark sought to be registered;
3. To the best of __________ (His or Her)
knowledge and belief no other person, partnership, corporation or association
has the right to use such mark in commerce, either in the identical form or in
such near resemblance to it as may be likely, when applied to the services of
such other person, to cause confusion, or to cause mistake, or to deceive;
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;
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.
___________________________________ _______________
Signature
of Partner Date
If
applicant is a corporation, state:
______________________________________
(Name of Corporate Officer), being hereby warned that willful false statements
and the like 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 from it, declares that:
1. __________ (He or She) is __________
(Official Title) of applicant corporation and is authorized to execute this
instrument on behalf of the corporation;
2. __________ (He or She) believes the
corporation to be the owner of the service mark sought to be registered;
3. 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 to it as may be likely, when applied to the services of such other
person, to cause confusion or mistake, or to deceive;
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.
___________________________________ _______________
Corporate
Name Date
___________________________________ _______________
Signature
of Corporate Officer Official
Title
___________________________________ _______________
Signature
of Applicant Date
Attach
designation of domestic representative, if necessary.
