APPLICATION FOR REGISTRATION OF TRADEMARK / SERVICE MARK State Form 4430 (R8 / 4-12) Approved by State Board of Accounts, 2006 FILING FEE: $ 10.00 CONNIE LAWSON SECRETARY OF STATE TRADEMARKS DIVISION 302 W. Washington St., Rm. E018 Indianapolis, IN 46204 Telephone: (317) 232-6540 INSTRUCTIONS: 1. If the Mark is the same or resembles a Mark presently registered in this state, attach an affidavit of consent by registrant, signed and verified under oath. 2. Section #5 should contain all the words you wish to register, even if Mark involves a symbol or design. 3. Complete section #7 and #12 only if applicable. All other sections should be completed. 4. Approximate dates of first use are acceptable in section #10. These dates must be prior to the date of signing this application. 5. Include three (3) flat specimens no larger than 8.5" x 11. If section #6 was answered yes, then an additional specimen must be included. This specimen should be on white plain paper showing only the Mark , in black ink and suitable for computer scanning. 6. Please visit our website at www.sos.in.gov. APPLICANT: INDIVIDUAL, ASSOCIATION, PARTNERSHIP, CORPORATION, OTHER 1. Name of applicant Telephone number of applicant ( 2. Address (number and street, city, state, and ZIP code) ) 3. Contact person (name and address of contact, if correspondence about this application should go to a party other than the signatory) Telephone number of contact person ( 4. Type of applicant: (check the appropriate box) ) Association Individual Corporation (State of Incorporation) ______________________________ Limited Liability Company (State of Organization) ________________ Partnership of any type (Attach name and address of all partners) Other (Describe) __________________________________________ TRADEMARK / SERVICE MARK INFORMATION 5. Trademark / Service Mark (include all words to be registered) 6. Does the Mark involve a symbol, design or any non-standard type face? If yes, then briefly describe, in thirty (30) words or less, major feature(s) of design. Yes No 7. DISCLAIMER: Disclaim words, phrases, and pictorial features which are merely descriptive of the goods or services or are primarily geographic. Names of cities, states, and designation of corporate status are normally considered descriptive; e.g., Inc., company, Indiana, USA, .com, etc. No claim is made to the exclusive right to use the symbol / word(s) ________________________________________________________________________________________________________ apart from the Mark as shown. 8. Class number (select only ONE class per form -- see page 2 for class) 9. Concisely describe specific goods (classes 1-34) or services (classes 35-45) used in connection with the Mark. The Mark is used on, or in connection with: 10. Date the Mark was first used in commerce in Indiana by applicant or predecessor: (month, day, year) Date the Mark was first used in commerce anywhere in USA, including Indiana: (month, day, year) 11. Check all boxes in either (a) or (b) that apply to how the Mark is used. Selection must correspond with the class chosen in section #8. (a) Trademark classes 1-34 only: (by applying it) Directly to goods to the containers for the goods to tags or labels affixed to the goods to tags or labels affixed to the containers for the goods by displaying the mark in physical association with the goods in the sale or distribution thereof Other: (please specify) ______________________ Other: (please specify) ___________________________ (b) Service Mark classes 35-45 only: (by displaying it) in advertisement of the service on documents, wrappers, or articles delivered in connection with the service rendered 12. If either of the above first uses of the Mark were by a predecessor in business, give name, address, and specify which use(s) of the Mark were by predecessor: Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com VERIFICATION STATEMENT I, _________________________________ affirm under penalty of perjury that (1) I am: (check box that applies) the individual owner, a partner, or an officer (title) _______________________________________ of applicant; (2) I have read this application and its contents / specimens are true and complete to the best of my knowledge; (3) The Mark is now in use in commerce; (4) (i) I am the owner of the applied for Mark and no other person or organization has the right to use this trademark / service mark in Indiana either in identical form or in a form so resembling it as might be calculated to deceive or be mistaken for it, or (ii) written consent by the registrant to applicants use has been filed with the Secretary of State. Signature Date (month, day, year) REQUIREMENTS FOR SPECIMENS: THREE (3) SPECIMENS MUST ACCOMPANY THIS FORM 1. The specimens must be actual samples of how the Mark is currently being used in commerce. The specimens may be identical or they may be examples of three different uses showing the same Mark. 2. If the Mark is used on goods (Classes 1-34), examples of acceptable specimens are tags or labels which are attached to the goods, displays associated with the goods, or photographs of the goods showing use of the Mark on the goods themselves. Invoices, letterhead, business cards, and brochures are generally not acceptable specimens for goods. 3. If the Mark is used for services (Classes 35-45), the specimens must show the Mark and include some clear reference to the type of services rendered under the Mark. Examples of acceptable specimens are signs, brochures about the services, advertisements, business cards or stationery, and photographs which show the Mark either as it is used in the rendering or promoting of the services. DISCLAIMERS: Descriptive words, phrases, and pictorial features which are essentially or merely descriptive of the character, quality, or intended function of the goods or services may not be claimed for registration except when specifically associated with other registrable features; in which case the descriptive matter must be disclaimed, unless the applicant can prove substantially exclusive and continuous use in this state or elsewhere for the five (5) years next proceeding the date of the filing of the application for registration. FILING NOTES: 1. Three (3) specimens and a separate non-refundable check or money order in the amount of $10.00, made to the order of Secretary of State of Indiana, must accompany this completed application. 2. A separate application (and $10.00 fee) mus