Trademark/service Mark Application Form - Kentucky Secretary Of State - 2012
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4COMMONWEALTH OF KENTUCKY
ALISON LUNDERGAN GRIMES
SECRETARY OF STATE
Trademark/Service Mark Application
Pursuant to the provisions of KRS 365.567 to 365.581, the undersigned hereby makes application for the registration of a
mark in Kentucky and for that purpose submits the following statements:
an individual
a corporation
other organization
1. The undersigned applicant is
a limited liability company
a partnership
(
__________________
Must check one)
a trademark registration a service mark registration
2. The applicant is applying for
(Must check one)
3. The name of the applicant: _______________________________________________________________________
4. The business address of the applicant is: street address ________________________________________________
city________________________________ state ____________________________ zip code __________________
5. If the applicant is a corporation or limited liability company, indicate the state of incorporation/organization: _________
6. If the applicant is a partnership, indicate the state of organization: _________________________________________
List the names of the general partners: ______________________________________________________________
(Attach a continuation sheet, if necessary)
7. If applying for a trademark, list the goods offered or sold under the mark. If applying for a service mark, list the services
provided under the mark: _________________________________________________________________________
_____________________________________________________________________________________________
8. The manner in which the mark is used in association with the above goods or services: ________________________
_____________________________________________________________________________________________
_
9. The class comprising the goods or services: (refer to class listing on page 4) ________________________________
10. List the dates the mark was first used: (a) anywhere: ________________ (b) in Kentucky: _____________________
11. Describe the mark (words and/or design) as shown on the attached drawing page (do not draw design on application)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
12. Disclaimer (if applicable*): No claim is made to the exclusive right to use the term____________________________
apart from the mark as shown. *see instructions
13. A drawing of all features of the mark for which ownership is claimed accompanies this application.
14. Three specimens showing actual use of the mark accompany this application.
The applicant declares the following: I am the owner of the mark and it is in use in the Commonwealth of Kentucky.
To my knowledge no other person has registered, either federally or in this state, or has the right to use the mark in this state
in an identical form or in such near resemblance as to be likely, when used on or in connection with the goods or services of
the other person to cause confusion or mistake, or to deceive.
I am ___________________________________ of ___________________________________________, the applicant herein, being first duly sworn,
say that I have read the above application and know the contents thereof, and that the facts set out therein are true, complete and correct.
________________________________________________
Signature
________________________________________________
State of ___________________________
Type or Print Name and Title
County of __________________________
Subscribed and sworn to before me this __________ day of ______________________, 20 _______.
_________________________________________________
Notary Public
(01/12)
My Commission Expires: _____________________________
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