SECRETARY OF THE STATE OFFICE
APPLICATION FOR A CERTIFICATE OF REGISTRATION OF A COLLECTIVE MARK Filing Fee: $50.00 Make Checks Payable to "Secretary of the State"
3. State or Country of Formation of the Owner, if other than a natural person: _____________________________________ (Partnerships reference & attach 8 1/2x11 list of partners)
1. Name of Applicant/Owner: _________________________________________________________________________________ 2. Address of Owner: __________________________________________ __________________________________________ __________________________________________ (Street/City/State/Zip Code) 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 marks: _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 7. The date on which the mark was first used anywhere: __________________________________ (month/day/year) 8. The date on which the mark was first used in Connecticut: _______________________________ (month/day/year) 9. The mode, manner or method of applying, affixing or otherwise using the mark on or in connection with such goods or services: ____________________________________________________________________________________________________ 10. Have applications to register the mark or portions or composites thereof been filed in the United States Patent Office?______ 11. If No. 10 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. 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. The applicant hereby declares under the penalties of false statement that the statements made in the foregoing application are true.
12. Date of Execution
13. _______________________________________ Name of Applicant
14. _______________________________________ Print/Type name of signatory
___________________________________________ Title of signatory if applicable: _________________ ___________________________________________ 15. _______________________________________ Business Address of Applicant Signature
16. 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