Form Tma-1-1.0 - Application For A Certificate Of Registration Of A Trade Or Service Mark Page 4
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512. Specific information regarding registration of the mark with the United States Patent and Trademark Office -
A. Complete only if the answer to the question presented in item number 11 is "yes".
B. Provide all of the requested information.
13. Name of Applicant:
A: If the owner is applying for registration of the mark, skip over number 13.
B. If the applicant is a person other than the owner, supply the applicant's full legal name and complete business
address.
14. Date of Execution: Provide the date on which the application is signed.
15. Name of Signatory: Print or type the name of the signatory.
A. If the owner/applicant is a natural person, leave the Title line blank
B. If the owner/applicant is not a natural person, e.g. a corporation, limited liability company, etc., provide the
signatory's title on the Title line.
16. Signature - The signatory named in item number 15 must provide an original signature.
17. Specimens or photocopies of the mark - All applications must include three identical specimens of the mark or three
identical photographs showing the mark as actually used. Examples of specimens include product labels,
advertisements, flyers, etc.
Please note that specimens which are derived from newspaper advertisements are not acceptable because they will
decay and cannot be maintained as part of this office's permanent records.
A. The specimens or photographs should not be attached to the application.
B. The specimens or photographs should not be larger than 3" X 3”.
OFFICE OF THE SECRETARY OF THE STATE
MAILING ADDRESS:
COMMERCIAL RECORDING DIVISION,
CONNECTICUT SECRETARY OF THE STATE,
P.O. BOX 150470,
HARTFORD, CT 06115-0470
DELIVERY ADDRESS:
COMMERCIAL RECORDING DIVISION,
CONNECTICUT SECRETARY OF THE STATE,
30 TRINITY STREET,
HARTFORD, CT 06106
PHONE: 860-509-6003
WEBSITE:
FORM TMA-1-1.0
DO NOT SCAN THIS PAGE
INSTRUCTIONS
Rev. 12/2010
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