Free Trademark / Service Mark Application - Massachusetts

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The Commonwealth of Massachusetts
William Francis Galvin Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512

Filing Fee $50.00 per class 5 year registration period

FORM MUST BE TYPED

Trademark / Service Mark Application
(General Laws Chapter 110H, Section 3)

FORM MUST BE TYPED

All information must be completed or this document will not be accepted for filing. (1) Applicant's name and business address: or b) Business Organization: _____________________________________________________________________________ Business address: _________________________________________________________________________________ Number Street _________________________________________________________________________________ City State Zip a) Individual: ______________________________________________________________________________________ Last First Middle Business address: _________________________________________________________________________________ Number Street _________________________________________________________________________________ City State Zip



(2) If applicant is a business, identify type (check box), and if applicable, state and date of organization: corporation limited liability company limited partnership partnership sole proprietor

other _________________________________________________________________________________________ (indicateentitytype) a) State of incorporation or organization: ____________ b) Date of incorporation or organization: _____________

(3) If applicant is a partnership, state the names of the general partners:

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(4) Applicant is seeking to register (check box): Trademark Service Mark

(5) The mark is (complete one of the following): a) Words only - If the mark is only words, the words in the mark are (include type style if it is claimed as part of the mark):

b) Design Only - If the mark is a design only, describe the design (include colors if they are claimed as part of the mark):

c) Words and Design - State the words in the mark (include color and type style if they are claimed as part of the mark) and describe the design:

(6) Describe briefly the goods or services used in connection with the mark:

(7) For each class provide the number and class in which such goods or services fall (see attached classification schedule): (Anapplicationmayincludemultipleclasses)

(8) Describe briefly how the mark is used in connection with such goods or services: a) The mark is used by displaying it (check box): on documents, wrappers, or articles delivered with the goods in advertisements of the services in connection with the services rendered other b) If other, describe briefly how the mark is used:

(9) The trademark or service-mark has been used by the applicant, or the applicant's predecessor in business, since ____________________________ and in the Commonwealth of Massachusetts since_____________________________ . (month,day,year) (month,day,year) (IffirstuseofthemarkanywherewasinMassachusetts,usethesamedateforboth.).

(10) a) Has the applicant or predecessor in interest filed an application for the same mark or portions of the same mark with the U.S. Patent and Trademark Office? Yes No b) If yes, for each application, provide (using additional pages if necessary): Filing date __________________________________ and serial number ___________________________________ . (month,day,year) c) What is the status of the application (check box)? awaiting examination approved for publication abandoned/withdrawn refusal (office action) issued registered

d) If finally refused, or not resulted in a registration, give reason: ______________________________________________ (11) Attach a sample showing the mark as actively used. The sample specimen may not be larger than 3" x 3".

The applicant is the owner of the mark. The mark is in use, and, to the knowledge of the person verifying the application, no other person has registered, either federally or in this state, or has the right to use such mark 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. I, _________________________________________________________ , state that I am the applicant or a lawfully authorized (NameofApplicant/AuthorizedRepresentative) representative of the applicant and declare under penalty of perjury that the foregoing application is true and correct. Executed on: _________________________________________________________________________________________ (Month,Day,Year) Signature: ____________________________________________________________________________________________

COMMONWEALTH OF MASSACHUSETTS
Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512

William Francis Galvin

Trademark / Service Mark Application
(General Laws Chapter 110H, Section 3)
Registered with

WILLIAM FRANCIS GALVIN
SecretaryoftheCommonwealth on: ___________________________________________ , 20 _________________ Trademark Section One Ashburton Place, Rm. 1717 Boston, MA 02108 Contact Information ________________________________________________________________ Name ________________________________________________________________ MailingAddress ________________________________________________________________ City/town State ZIP ________________________________________________________________ Telephone Email