Form No. T-81 - Application For The Registration Of A Service Mark Form

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ID No. ___________

STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS

Office of the Secretary of State

Corporations Division

Trademark Section

148 W. River Street

Providence, Rhode Island 02904-2615

APPLICATION FOR THE REGISTRATION OF A SERVICE MARK

TO BE TYPED-PLEASE READ INSTRUCTIONS BEFORE COMPLETING THIS FORM

1. Name of Applicant _____________________________________________________________________________________________________

2. (a) Principal business address ____________________________________________________________________________________________

Street

_____________________________________________________________________________________________________________________

City/Town

State

Zip Code

(b) Business address in Rhode Island, if any. [To be filled in only if principal business address is not in Rhode Island.]

_____________________________________________________________________________________________________________________

Street

City/Town

State

Zip Code

3. State whether applicant is an individual, partnership, corporation, limited liability company, union or association:

________________________________________________________________________________________

4. If an entity, what is the state of incorporation? _______________________________________________________________________________

5. Describe mark (1): _____________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

6. Describe the specific services in connection with which mark is used: _____________________________________________________________

_____________________________________________________________________________________________________________________

7. Class No. (2) __________________________________________________________________________________________________________

8. Check how the mark is used. By applying it:

____ in advertisements of the service

____ on documents, wrappers or articles delivered in connection with the service rendered

____ in other fashions, if so specify: _______________________________________________________________________________________

9. Date of the first use of mark by applicant or predecessor. [If first use of mark was in Rhode Island, use same date in both (a) and (b).]

(a) Anywhere ________________________________________________________________________________________________________

(b) In Rhode Island ____________________________________________________________________________________________________

10. If either of the above first uses was by a predecessor of applicant, state which use or uses were by a predecessor and identify the predecessor.

________________________________________________________________________________________

11. The applicant is the owner of the mark, the mark is in use, and to the best knowledge of the person verifying the application, no other person has

registered in this state or has the right to use such mark in this state 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 person, to cause confusion or to cause mistake or to deceive.

________________________________________________________

Name of Applicant

_______________________________________________________

Signature of Applicant or Authorized Representative of Applicant

STATE OF _________________________

COUNTY OF _______________________

________________________________________________________

Title

In __________________________, on this ____________ day of ________________________, 20___, personally appeared before me

______________________________________________________, who, being by me first duly sworn, declared that he/she signed the foregoing

application in the capacity indicated and that the statements contained therein are true, complete and correct.