SECRETARY OF THE STATE OF CONNECTICUT 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: www.concord-sots.ct.gov APPLICATION FOR A CERTIFICATE OF REGISTRATION OF A TRADE OR SERVICE MARK USE INK. COMPLETE ALL SECTIONS. PRINT OR TYPE. ATTACH 81/2 X 11 SHEETS IF NECESSARY. FILING PARTY (CONFIRMATION WILL BE SENT TO THIS ADDRESS): FILING FEE: $50 MAKE CHECKS PAYABLE TO "SECRETARY OF THE STATE" NAME: ADDRESS: CITY: STATE: ZIP: 1. NAME OF OWNER OF MARK: 2. ADDRESS OF OWNER: ADDRESS: CITY: STATE: ZIP: 3. STATE OR COUNTRY OF FORMATION OF THE OWNER (IF OTHER THAN A NATURAL PERSON): (PARTNERSHIPS - REFERENCE & ATTACH 81/2 X 11 LIST OF PARTNERS) 4. PLEASE PROVIDE A COMPLETE DESCRIPTION OF THE MARK: 5. THE GOODS OR SERVICES ON OR IN CONNECTION WITH WHICH THE MARK IS USED: 6. USE THIS SPACE TO DISCLAIM THE EXCLUSIVE RIGHT TO USE ANY DESCRIPTIVE, GENERIC OR GEOGRAPHICALLY DESCRIPTIVE COMPONENTS OF THE MARK: 7. THE CLASS OF THE GOODS OR SERVICES STATED IN ITEM NUMBER 5: NOTE: ONE APPLICATION PER GOOD/SERVICE. PAGE 1 OF 2 FORM TMA-1-1.0 Rev. 12/2010 American LegalNet, Inc. www.FormsWorkFlow.com 8. THE DATE ON WHICH THE MARK WAS FIRST USED ANYWHERE: 9. THE DATE ON WHICH THE MARK WAS FIRST USED IN CONNECTICUT: 10. THE MODE, MANNER OR METHOD OF APPLYING, AFFIXING OR OTHERWISE USING THE MARK ON OR IN CONNECTION WITH SUCH GOODS OR SERVICES: 11. HAVE APPLICATIONS TO REGISTER THE MARK OR PORTIONS OR COMPOSITES THEREOF BEEN FILED IN THE UNITED STATES PATENT OR TRADEMARK OFFICE? Yes No 12. IF NO. 11 WAS ANSWERED YES, INDICATE THE FILING DATE, SERIAL NUMBER, STATUS, AND IF REGISTRATION WAS REFUSED, THE REASONS FOR SUCH REFUSAL: THE APPLICANT IS THE OWNER OF THE MARK OR THE OWNER'S REPRESENTATIVE. THE APPLICANT ASSERTS THAT THE MARK IS NOT KNOWN TO BE THE SUBJECT MATTER OF AN EXISTING FEDERAL REGISTRATION GRANTED TO ANOTHER AND TO THE BEST OF THE APPLICANT'S KNOWLEDGE, NO OTHER PERSON HAS THE RIGHT TO USE SUCH MARK IN THIS STATE 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 PURCHASERS. THE APPLICANT HEREBY DECLARES UNDER THE PENALTIES OF FALSE STATEMENT THAT THE STATEMENTS MADE IN THE FOREGOING APPLICATION ARE TRUE. 13. NAME OF APPLICANT (IF OTHER THAN OWNER): BUSINESS ADDRESS OF APPLICANT ADDRESS: CITY: STATE: ZIP: 14. EXECUTION: DATED THIS 15. NAME OF SIGNATORY DAY OF CAPACITY/TITLE OF SIGNATORY (If applicable) , 20 16. SIGNATURE 17. THE APPLICANT MUST SUBMIT THREE SPECIMENS OR PHOTOGRAPHS OF THE MARK AS ACTUALLY USED IN THIS STATE. PAGE 2 OF 2 FORM TMA-1-1.0 Rev. 12/2010 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS The following series of instructions have been compiled to assist you in completing the Application for Registration of a Connecticut Trade or Service Mark form. Numbers appearing on this instruction correspond with numbered blanks appearing on the form.Examples provided in these instructions are fictitious and have been included to illustrate applications of the instructions provided. 1. Name of Owner of Mark - Provide full legal name of the individual or organization who or which actually owns the mark. 2. Address of owner of Mark - Provide full street address of mark's owner. Include street, city, state and zip code. 3. State or Country of Formation of the Owner - Complete only if owner is not a natural person by providing the owner's state of formation. A. Note: if the owner of the mark is a partnership, it must attach a list of its partners to the application. 4. Description of the Mark - Provide in words, a full description of the mark intended to be registered. A. If the mark is composed of words alone, the description need only restate those words. 1. Example - The mark is SPINTECH. The description is SPINTECH. B. Logos, pictorial features, colors, or distinctive print styles, which are components of the mark, must be described in writing. 1. Example description - SPINTECH appearing in yellow block letters in the center of three horizontally arrayed silver gears. C. Please note that the written description defines the registration. All searches conducted by this office are based upon the written description. It is important, therefore, to include all relevant description of the mark in item number 4. Drawings or references to attached specimens will not substitute for a full written description and must not appear in item number 4. 5. The goods or services on or in connection with which the mark is used - Provide the type of the goods or services, which the mark identifies. This is usually a description of what the owner produces, e.g., Tires for a manufacturer of Tires - Real Estate Services for a Real Estate Agency. 6. Disclaimers - The exclusive right to use any generic, descriptive or geographically descriptive terms or features of the mark must be disclaimed on the application. If such terms or features are not disclaimed, the application will have to be returned for correction. Whether or not components of a mark must be disclaimed depends largely upon the goods or services in connection with which it is used. A. Example 1. The mark is described as: The words "Quickie Grocery of Meriden" contained within a bright orange triangle. 2. The services in connection with which the mark is used is: Grocery store services. 3. The disclaimer required is: The owner hereby disclaims the exclusive right to use the terms "Grocery" & Meriden". 7. The class of goods or services - Select from the list of classes provided in section 35-11h of the Connecticut General Statutes. (This list has been reproduced for your convenience and included within the application package). A. Select the class into which the goods or services stated in item number 7 fall. If your mark identifies goods, select a class from the group of trademark classes only. Otherwise, if your mark identifies services, select a class from the group of service mark classes only. B. If you cannot find a class into which your mark falls please choose the appropriate miscellaneous class, 20 for goods, 42 for services. C. Only one class may be selected per application. Separate applications must be completed for marks, which identify multiple