Trademark Service Mark Application (General Laws Chapter 110h, Section 3) - Commonwealth Of Massachusetts Page 3

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(9) The trademark or service-mark has been used by the applicant, or the applicant’s predecessor in business, since
____________________________ and in the Commonwealth of Massachusetts since_____________________________ .
(month, day, year)
(month, day, year)
(If first use of the mark anywhere was in Massachusetts, use the same date for both.).
(10) a) Has the applicant or predecessor in interest filed an application for the same mark or portions of the same mark with the
U.S. Patent and Trademark Office?
Yes
No
b) If yes, for each application, provide (using additional pages if necessary):
Filing date __________________________________ and serial number ___________________________________ .
(month, day, year)
c) What is the status of the application (check box)?
awaiting examination
refusal (office action) issued
approved for publication
registered
abandoned/withdrawn
d) If finally refused, or not resulted in a registration, give reason: ______________________________________________
(11) Attach a sample showing the mark as actively used. The sample specimen may not be larger than 3” x 3”.
The applicant is the owner of the mark. The mark is in use, and, to the knowledge of the person verifying the application, no other
person has registered, either federally or in this state, or has the right to use such mark 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.
I, _________________________________________________________ , state that I am the applicant or a lawfully authorized
(Name of Applicant / Authorized Representative)
representative of the applicant and declare under penalty of perjury that the foregoing application is true and correct.
Executed on: _________________________________________________________________________________________
(Month, Day, Year)
Signature: ____________________________________________________________________________________________

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