Mark:  ____________________________________


Class Number:  _____________________________




(Insert appropriate identification of applicant) 


The above identified applicant has adopted and is using the ________________________ (Trademark or Service Mark) shown in the accompanying drawing for the following described ____________________ (Goods or Services), and requests that the mark be registered in the United States Patent and Trademark Office on the Principal Register established by the Act of July 5, 1946, for the area comprising _____________________ (List States for which Registration is Sought). 


The trademark was first used on the goods on __________ (Date); was first used on the goods in __________________________ (Type of Commerce) commerce on __________ (Date); and is now in use in such commerce.


(Insert one of the following paragraphs as applicable:  The mark has been in lawful use in commerce or in connection with the goods for the year preceding the filing of this application or The mark has not been in use in commerce for the full year preceding the filing of this application, but applicant requires domestic registration as a basis for foreign protection of the mark.)


The mark is used by applying it to _____________________________ (Insert Manner or Method of Using the Mark with the Goods, such as:  the goods or the containers for the goods or displays associated with the goods or tags or labels affixed to the goods or other method which may be in use), and five specimens showing the mark as actually used are presented herewith.


The following ____________________________________ (Exception or Exceptions) to applicant’s right to exclusive use are:


By:  ___________________ (Name), doing business at ____________________ (Address, Including Street, City and State), who is using the mark ___________________________ (Identify Mark and Registration Number or Serial Number, if any) for ____________________ (Common, Usual or Ordinary Name of Goods or Services) in the States of __________ by applying the mark to ____________ from __________ (Earlier Known Date of Such Use) to the present.


(Insert appropriate verification or declaration and add, after the word association the words other than those authorized by applicant.)


1Attach designation of domestic representative, if necessary.