Form Tm 1 - Application For Registration Of A Trademark Or Service Mark (Page 2 of 2) in pdf

TM 1 (11/09)

COMMONWEALTH OF VIRGINIA

STATE CORPORATION COMMISSION

DIVISION OF SECURITIES AND RETAIL FRANCHISING

APPLICATION FOR REGISTRATION OF A TRADEMARK OR SERVICE MARK

(Please type or print)

Applicant (owner) name and address:____________________________________________________________________

__________________________________________________________________________________________________

Contact person name and address:_______________________________________________________________________

______________________________Daytime phone:_______________________ Fax number:______________________

Applicant is a:_______________________________Applicant's state or jurisdiction of formation: ___________________

(entity type i.e. corporation, partnership, etc)

Kind of mark (check one): Trademark ___ Service Mark ___

Identify the trademark or service mark (or attach an exhibit of the exact mark): __________________________________

__________________________________________________________________________________________________

Class number(s) of goods or services (see 21 VAC 5-120-100):________________________________________________

Describe the product(s) or service(s) the mark represents (identifies):___________________________________________

__________________________________________________________________________________________________

Date mark was first used anywhere by applicant or applicant's predecessor: _____________________________________

Date mark was first used in Virginia by applicant or applicant's predecessor: ____________________________________

PLEASE NOTE: A specimen of the mark must accompany this application.

The applicant asserts that it is the owner of this mark and that the mark is in use in the Commonwealth of Virginia. No

other person has registered this mark or has the right to use this mark in Virginia, 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

mistake, or to deceive.

(NOTE: The application must be signed in the name of the applicant, either by the applicant or by a person authorized by

the applicant. The application must be sworn to by the person who signed the name of the applicant.)

Signature:___________________________________________________________Date: __________________________

Signer’s Name:_______________________________________________________Title:__________________________

(print or type)

State of:_____________________________________, County/City of:___________________________________, to-wit:

The foregoing application was subscribed and sworn to before me by __________________________________________

on the ___________________________ day of ______________________________, ____.

My Commission Expires:_______________________________ Notary Public: __________________________________

Form Tm 1 - Application For Registration Of A Trademark Or Service Mark Page 2