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SECRETARY OF THE STATE OFFICE

APPLICATION FOR A CERTIFICATE OF REGISTRATION OF A COLLECTIVE MARK

Filing Fee: $50.00 Make Checks Payable to “Secretary of the State”

1. Name of Applicant/Owner: _________________________________________________________________________________

2. Address of Owner:

3. State or Country of Formation of the Owner, if

__________________________________________

other than a natural person:

__________________________________________

_____________________________________

__________________________________________

(Partnerships – reference & attach 8 1/2x11 list of

(Street/City/State/Zip Code)

partners)

4. Please provide a complete description of the mark:

_____________________________________________________________________________________________________

____________________________________________________________________________________________________

5. The goods or services on or in connection with which the mark is used:

____________________________________________________________________________________________________

____________________________________________________________________________________________________________

6. Use this space to disclaim the exclusive right to use any descriptive or generic components of the marks:

_____________________________________________________________________________________________________

____________________________________________________________________________________________________________

7. The date on which the mark was first used anywhere: __________________________________ (month/day/year)

8. The date on which the mark was first used in Connecticut: _______________________________ (month/day/year)

The mode, manner or method of applying, affixing or otherwise using the mark on or in connection with such goods or services:

____________________________________________________________________________________________________

______

10.

Have applications to register the mark or portions or composites thereof been filed in the United States Patent Office?

11.

If No. 10 was answered Yes, indicate the filing date, serial number, status, and if registration was refused, the reasons for such refusal:

______________________________________________________________________________________________________

The applicant is the owner of the mark. The applicant asserts that the mark is not known to be the subject matter of an existing federal registration granted to another

and to the best of the applicant's knowledge, no other person 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 other person, to cause confusion, or to cause mistake or to deceive the public. The applicant

hereby declares under the penalties of false statement that the statements made in the foregoing application are true.

12. Date of Execution

13. _______________________________________

14. _______________________________________

Name of Applicant

Print/Type name of signatory

_________________

___________________________________________

Title of signatory if applicable: _________________

month./day/year

___________________________________________

15. _______________________________________