Free Registration of Emblem form draft 2.indd - West Virginia

Natalie E. Tennant Secretary of State State Capitol Bldg., Ste. 157-K 1900 Kanawha Blvd. E. Charleston, WV 25305-0770

WEST VIRGINIA APPLICATION FOR REGISTRATION OF EMBLEMS, ETC.
Under WV Code 35A-1 et.seq.

Penney Barker, Manager BUSINESS & LICENSING DIVISION Tel: (304) 558-8000 Fax: (304) 558-8381 Hours: 8:30 a.m. - 5:00 p.m. ET

Applicant Information
1. 2. Name of organization, etc.: Address:

3.

Chief officer(s) making application:

4.

Brief description of organization and its activities:

5.

Brief description of emblem:

A facsimile or duplicate of the emblem is attached, marked Attachment 1.

Verification
I, as applicant, hereby certify that: (1) the organization, etc. is the owner of the emblem for which this application is made; (2) the emblem is in use; (3) to my knowledge, no other person has registered, either federally or in this state, or has the right to use this emblem either in the identical form thereof or in such near resemblance to it as to be likely to cause confusion, or to cause mistake, or to deceive; and (4) the information contained in this application is true, to the best of my knowledge.

DATE SIGNED

NAME OF PERSON SIGNING (TYPE OR PRINT)

SIGNATURE

TITLE OF MEMBER OR OFFICER SIGNING:

FORM EMB-1

Issued by the West Virginia Secretary of State

Revised 1/09

West Virginia Application for Registration of Emblems, etc.

Attachment 1

Print applicant's name on line provided. Leave effective date and serial number blank. Place drawing or photo-copied representation of emblem vertically within the frame. If necessary, enlarge or reduce so that longer dimension is no less than 5" and no more than 6". Organization's Name: Effective Date:

Return to:

West Virginia Secretary of State Business & Licensing Division State Capitol Bldg., Ste. 157-K 1900 Kanawha Blvd. E. Charleston, WV 25305-0770

Please enclose check in the amount of $10.00 payable to West Virginia Secretary of State.
FORM EMB-2