Statement Of Trademark Registration Of An Individual Not A Resident Of Colorado Page 2
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1
2
3Street address
______________________________________________________
(Street number and name)
______________________________________________________
__________________________
CO
____________________
(City)
(State)
(Zip Code)
Mailing address
______________________________________________________
(leave blank if same as street address)
(Street number and name or Post Office Box information)
______________________________________________________
__________________________
CO
____________________.
(City)
(State)
(Zip Code)
The person appointed as registered agent has consented to being so appointed.
4.
(Mark the applicable box and complete the statement. Caution: Mark only one box.)
The trademark is a standard character trademark and the characters constituting the trademark are
__________________________________________________________________________________.
OR
The trademark is a special form trademark and a description of the attached drawing is
__________________________________________________________________________________.
5. A detailed description of the goods or services in connection with which the trademark is used is
____________________________________________________________________________________.
The class into which such goods or services fall is ___________________________________________.
(Class)
6. A description of the attached specimen sufficient to identify the nature of the specimen is
_____________________________________________________________________________________.
7. The date of first use in commerce of the trademark in this state by such individual or such individual’s
predecessor in interest is __________________________.
(mm/dd/yyyy)
8. The registrant identified above is currently using the trademark in commerce in this state and such registrant
believes, in good faith, that such registrant has the right to use the trademark in connection with the goods
or services listed above and such registrant’s use of the trademark does not infringe the rights of any other
person in that trademark.
9.
(If applicable, adopt the following statement by marking the box and include an attachment.)
This document contains additional information as provided by law.
Notice:
Causing this document to be delivered to the Secretary of State for filing shall constitute the affirmation or
acknowledgment of each individual causing such delivery, under penalties of perjury, that such document is
such individual's act and deed, or that such individual in good faith believes such document is the act and deed
of the person on whose behalf such individual is causing such document to be delivered for filing, taken in
conformity with the requirements of part 3 of article 90 of title 7, C.R.S. and, if applicable, the constituent
documents and the organic statutes, and that such individual in good faith believes the facts stated in such
document are true and such document complies with the requirements of that Part, the constituent documents,
and the organic statutes.
TDMK_NOTCO
Page 2 of 3
Rev. 10/31/2011
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