To:  The Secretary of State of the State of ________________________________________


The undersigned applies to register the trademark described herein pursuant to ________________________________ (Cite Statute), and affirms under the penalties of perjury that the statements made herein and on the papers attached hereto are true.


Name of applicant:  _____________________________________


Address:  _________________________________________________________________


If corporation, state of incorporation:  ___________________________________________


If partnership, names and addresses of all partners: 



Description of trademark:  ____________________________________________________


Specific goods or services on or in connection with which the trademark is used:  __________________________________________________________________________


Manner in which trademark is placed on goods or otherwise used in connection with applicants goods or services:  __________________________________________________


Name of class and classification number of goods or services:  _______________________


Date of first use of trademark:  _____________________


In State of:  ________________________________                       _______________ (Date). 

Elsewhere:  ________________________________                       _______________ (Date). 

Send certificate of registration and communications with respect to this application to:  ____________________________________________________________ (Name and Mailing Address of Applicant or Agent Authorized to Prosecute Application).


Applicant is the owner of the trademark described herein, and no other person has the right to use such trademark in this state, either in the identical form or in such near resemblance thereto as might be calculated to deceive, or be mistaken for, such trademark.


Three samples or facsimiles of such trademark are attached hereto.




___________________________________                       __________________

Signature                                                                               Date