Application For A Certificate Of Registration Of A Trade Or Service Mark - Connecticut Secretary Of State

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SECRETARY OF THE STATE OFFICE
30 TRINITY STREET, P.O. BOX 150470
HARTFORD, CT 06 I 15-0470
APPLICATION
FOR A CERTIFICATE
OF REGISTRATION
OF A TRADE OR SERVICE
MARK
Rev. I2/1999
1. Name of Owner of Mark:
1. Address of Owner:
3. State or Country of Formation of the Owner, zy
other than a natural person:
(Partnerships - reference & attach 8 112x 11 list of
(Street/City/State/Zip Code)
partners)
1. 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, generic or
7. The Class of the goods or services stated in
geographically descriptive components of the mark:
item number 5:
NOTE: One application per good/service.
6. 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 or Trademark Office?
12.
If No. I I 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 or
the owner’s representative. 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 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
ifother than Owner
Print/Type name of signatory
month.ldaylyear
Title of signatory if applicable:
16.
Business Address of Applicant
Signature
17. The applicant must submit three specimens or photographs
of the mark as actually used in this state.
Please make appropriate reference to attachments if additional space is needed

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