Mark Registration Application SDCL 37-6-5 State of South Dakota Filing Fee: $100.00 - please make check payable to the Secretary of State Attach two samples or facsimiles of the Mark, no larger than 8 1/2" x 11" 1. Applicant: ___________________________________________________________________________________ Address: ___________________________________________ City: _____________________________________ County: ___________________________________ State: ____________________ Zip _____________________ Business Telephone Number: ________________________________ 2. If a Corporation, where incorporated: ______________________________________________________________ 3. If a partnership, list name and address of partner(s): 4. Name of Mark: 5. Description of goods or services connected with Mark: 6. Mode or manner in which the Mark is used: 7. Classification of Goods or Services Number: ________________ 8. Date the Mark was first used by Applicant or Predecessor: a. In the United States: ___________________________________________ b. In the State of South Dakota: ____________________________________ Trademark Application1.doc 02/13/2004 7:05 AM Page 1 of 2 *** This section is to be completed in the presence of a Notary Public **** State of ___________________________) )§§ County of _________________________) I, ____________________________________________________, _______________________________________ (Print Name of Applicant) (Title) of _____________________________________________________________________________________________ (Print Corporation-Partnership-Association) do solemnly swear that the above named applicant is the owner of the Mark and that no other person has the right to use such Mark in the State of South Dakota either in the identical form thereto as might be calculated to deceive or to be mistaken therefore. By: ___________________________________________ (Applicant Signature) Subscribed and sworn to before me this ________ day of ____________________________________. (Month/Year) _____________________________________________ (Notary Public) My commission expires:___________________ (Notarial Seal) Return to: SECRETARY OF STATE State Capitol Building 500 East Capitol Pierre, SD 57501 (605)773-3539 e-mail trademark@state.sd.us Trademark Application1.doc 07/12/2005 2:35 PM Page 2 of 2