Form Mark-3 - Application For Amendment Page 2
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5E.
I, ______________________________________________________________________________________________ believe
(Print/Type Name and Capacity)
______________________________________________________________________________________________________
(“Myself”, Firm, Association or Corporate Name)
to be the owner of the accompanying mark and that “no other person to the best of my knowledge and belief has the right to
use the mark in this state as a mark or as a trade name or as a corporate name either in the identical form thereof or in such
near resemblance thereto as to be likely, when applied to the goods or services of the other person, to cause confusion or to
cause mistake or to deceive.” (10 MRSA §1522.2.D)
______________________________________________________________________________________________________
Signature of Applicant (Individual, Corporate or Association Officer)
______________________________________________________________________________________________________
(Mailing Address, City, State and Zip Code)
F.
Applicant is a (an)
! individual
! general partnership
! limited partnership
! corporation
! association
! union
! other __________________________________________________________
(Explain)
If a corporation, limited partnership, limited liability company or limited liability partnership the state of
incorporation/organization is _____________________________ and the date of incorporation/organization is
________________________
G.
Date of this application ____________________
You MUST submit THREE (3) samples of the mark text and/or design with this application. If the mark is to be protected in
color, all the samples must be in the appropriate colors. NOTE: Samples may be 3 of the same item, i.e. business cards,
letterhead, etc.
THE EXECUTION OF AN APPLICATION CONTAINING FALSE STATEMENTS WHICH ONE DOES NOT BELIEVE
TO BE TRUE IS PUNISHABLE AS A CLASS D CRIME ACCORDING TO THE MAINE CRIMINAL CODE, 17-A MRSA
§453, “UNSWORN FALSIFICATION”.
SUBMIT COMPLETED FORMS TO: CORPORATE EXAMINING SECTION, SECRETARY OF STATE,
101 STATE HOUSE STATION, AUGUSTA, ME 04333-0101
FORM NO. MARK-3 Rev. 4/16/2001
TEL. (207) 624-7752
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