Application For Registration Of A Certification Mark - Connecticut Secretary Of The State

SECRETARY OF THE STATE OFFICE

APPLICATION FOR REGISTRATION OF A CERTIFICATION 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

7. The mark is used to certify the following:

components of the mark:

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

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

10.

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

____________________________________________________________________________________________________

______

11.

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

12.

If No. 11 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 and is not engaged in the production or marketing of any goods or services to which the mark is applied. 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 purchasers. The applicant hereby declares under the penalties of false statement that

the statements made in the foregoing application are true.

13. Date of Execution

14. _______________________________________

15. ______________________________________

Name of Applicant

Print/Type name of signatory

_________________

___________________________________________

Title of signatory if applicable: ________________

month/day/year

___________________________________________

16. ______________________________________

Business Address of Applicant

Signature

The applicant must submit three specimens or photographs of the mark as actually used in this state.

17.

Please make appropriate reference to attachments if additional space is needed

Rev. 08/24/2007