Free Microsoft Word - app for reg of a certification mark.DOC - Connecticut

SECRETARY OF THE STATE OFFICE

APPLICATION FOR REGISTRATION OF A CERTIFICATION MARK Filing Fee: $50.00
1. Name of Applicant/Owner:

Make Checks Payable To "Secretary of the State"

2. Address of Owner: __________________________________________ __________________________________________ __________________________________________ (Street/City/State/Zip Code)

3. State or Country of Formation of the Owner, if other than a natural person: ___________________________________ (Partnerships ­ reference & attach 8 1/2x11 list of partners)

4. Please provide a complete description of the mark: _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 5. The goods or services on or in connection with which the mark is used: ____________________________________________________________________________________________________
6. Use this space to disclaim the exclusive right to use any descriptive or generic components of the mark: 7. The mark is used to certify the following:

8. The date on which the mark was first used anywhere: __________________________________ (month/day/year) 9. The date on which the mark was first used in Connecticut: _______________________________ (month/day/year) 10. The mode, manner or method of applying, affixing or otherwise using the mark on or in connection with such goods or services: ____________________________________________________________________________________________________ 11. Have applications to register the mark or portions or composites thereof been filed in the United States Patent Office? ______ 12. If No. 11 was answered Yes, indicate the filing date, serial number, status, and if registration was refused, the reasons for such refusal: ______________________________________________________________________________________________________
The applicant is the owner of the mark and is not engaged in the production or marketing of any goods or services to which the mark is applied. The applicant asserts that the mark is not known to be the subject matter of an existing federal registration granted to another and to the best of the applicant's knowledge, no other person has the right to use such mark in this state either in the identical form thereof or in such near resemblance thereto as to be likely, when applied to the goods or services of such other person, to cause confusion, or to cause mistake or to deceive the public purchasers. The applicant hereby declares under the penalties of false statement that the statements made in the foregoing application are true.

13. Date of Execution

14. _______________________________________ Name of Applicant

15. ______________________________________ Print/Type name of signatory

_________________
month/day/year

___________________________________________ Title of signatory if applicable: ________________ ___________________________________________ 16. ______________________________________ Business Address of Applicant Signature

17. The applicant must submit three specimens or photographs of the mark as actually used in this state.

Please make appropriate reference to attachments if additional space is needed
Rev. 08/24/2007