OFFICE OF SECRETARY OF STATE CORPORATIONS DIVISION 237 Coliseum Drive Macon, Georgia 31217 (404) 656-2817 Trademark Search and Status Information on the Internet sos.georgia.gov/corporations/marksearch.htm Brian Kemp Secretary of State APPLICATION FOR REGISTRATION TRADEMARK OR SERVICE MARK DO NOT WRITE IN SHADED AREA - SOS USE ONLY DOCKET # REGISTRATION # DOCKET CODE DATE FILED MARK VERIFICATION AMOUNT RECEIVED CHECK/ RECEIPT # NOTICE TO APPLICANT: PRINT PLAINLY OR TYPE REMAINDER OF THIS FORM. In compliance with the requirements of O.C.G.A. §§10-1-440 et seq., the undersigned, having adopted and used a Trademark or Service Mark in this state for the purposes provided in that Code Chapter and desiring to file the same for public record in the Office of the Secretary of State of Georgia, does hereby certify the following: 1. Name of Applicant 2. Principal Business Address City State Zip Code 3. If applicant is an entity, please indicate the state of incorporation/formation/organization: 4. Describe the mark. The description you provide is the way the mark will be registered. (See General instructions) (Attach additional sheet if necessary) 5. (A) If a trademark, what goods are offered or sold under the mark? OR (B) If a service mark, what services are provided under the mark? 6. Class No: 7. Date of first use of the mark by applicant, predecessor, or licensee. (Give Month, Day and Year) (A separate application must be filed for each class in which a registration of the mark is sought.) (A) Anywhere: 8. (B) In Georgia: The applicant is the owner of the mark described herein, the mark is in use in this state, and to the best of his/her knowledge, no other person except the applicant has registered the mark either federally or in this state, or has the right to use such mark in this state either in its identical form 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 mistake, or to deceive. Signature of Applicant Print Name Official Title (If signing for an entity) Phone Number Mail or deliver to the Secretary of State, at the above address, the following: 1) This COMPLETED and notarized application. 2) Three (3) specimens of the mark as currently used. May be 3 samples of the same specimen. If trademark, should be actual label or packaging used on product. If service mark, should be advertising such as newspaper ad, brochure, etc. depicting the service rendered. If specimens are bulky or of value, i.e., jewelry, t-shirts, caps, etc., please submit photographs of the actual specimens. The photos should clearly and legibly depict the mark along with all material pertinent to the registration. 3) A filing fee of $15.00 payable to the Secretary of State. Filing fees are NON-refundable. STATE OF COUNTY OF Sworn to and subscribed before me this Day of , 20 My Commission Expires NOTARY PUBLIC FORM TMAPPL American LegalNet, Inc. www.FormsWorkFlow.com