Form T-3 - Application For Registration Of Service Mark - 2001

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FORM T-3

WWW.

USINESS

1/2001

Nonrefundable Filing Fee: $50.00

STATE OF HAWAII

DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS

Business Registration Division

1010 Richards Street

Clear Form

Mailing Address: P.O. Box 40, Honolulu, Hawaii 96810

APPLICATION FOR REGISTRATION OF SERVICE MARK

(Chapter 482, Hawaii Revised Statutes)

PLEASE TYPE OR PRINT LEGIBLY IN BLACK INK

Applicant’s Name:______________________________________________________________________________________________________

Applicant’s Address: ____________________________________________________________________________________________________

(including city, state, and zip code)

Registration is (check one):

New

Renewal

Status of Applicant (check only one):

Sole Proprietor

Corporation

Partnership

LLC

LLP

Unincorporated Association

Other (explain): ________________________________________________________________

If applicant is an entity, list state or country of incorporation/formation/organization: __________________________________________________

Service Mark is specifically described as: ____________________________________________________________________________________

_____________________________________________________________________________________________________________________

Applicant is (check one):

Originator of mark

Assignee (one to whom mark was assigned to by another)

Service mark is being used in connection with the following services: ______________________________________________________________

_____________________________________________________________________________________________________________________

I certify, under the penalties set forth in Section 482-3.5, Hawaii Revised Statutes, that (check one):

I am the applicant

I am the ______________________________________________________________________________

(Office Held)

of the applicant named in the foregoing application, and that the statements made in the application are true and correct to the best of my knowledge

and belief.

_________________________________________________________________________

________________________________________

(Signature)

(Date)

SEE INSTRUCTIONS ON REVERSE SIDE. Application must be certified by the applicant if an individual. For corporations, application must be signed

by an authorized officer of the corporation. General or limited partnerships must be signed by a general partner. For LLC, must be signed and certified

by a manager of a manager-managed company or by a member of a member-managed company. LLP must be signed and certified by a partner.

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(DEPARTMENTAL USE ONLY)

_____________________

Certificate of Registration No.

CERTIFICATE OF REGISTRATION OF SERVICE MARK

In accordance with the provisions of Chapter 482, Hawaii Revised Statutes, this Certificate of Registration is issued to secure the aforesaid applicant

the use of the said SERVICE MARK throughout the State of Hawaii for the term of: _____________________________________________ year(s)

from _____________________________________________ to _____________________________________________ .

DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS

STATE OF HAWAII

REGISTRATION OF A SERVICE MARK WITH

THE DEPARTMENT DOES NOT GRANT YOU

Dated: ___________________________________________________________

OWNERSHIP OF THE SERVICE MARK

________________________________________________________________

(Director of Commerce and Consumer Affairs)

B48 (Fee)

S18 (SH)