PAUL D. PATE Secretary of State State of Iowa Application for Registration of Mark One actual facsimile or specimen of mark must accompany this application Pursuant to Iowa Code Chapter 548, the undersigned applies for registration of a trademark or service mark entitled to registration under this chapter in the state of Iowa. READ THE INSTRUCTIONS CAREFULLY BEFORE STARTING THE APPLICATION. All items must be completed before the application will be considered. Attach additional pages as needed to provide the requested information. Other documents or materials may also be attached to support the application. 1. Name of applicant: 2. Business address of applicant: 3. The applicant is (check one): an individual a partnership a corporation other (please specify) ______________________ 3a. If a corporation or other business entity, the state of incorporation or registration: 3b. If the applicant is a partnership, the state in which the partnership is organized: The names of the general partners: 4. The type of business engaged in by the applicant: 5. Goods or services with which the proposed mark is to be attached: 6. The class number and title of the good or service (only one class per application): 7. Manner in which the proposed mark will be used in conjunction with the good or service: 8. A complete description of the mark: 635_0107 1/15 (continued on the reverse) American LegalNet, Inc. www.FormsWorkFlow.com 9. Any components of the mark which the applicant disclaims exclusive use: 10. Date of first use by applicant or applicant's predecessor in interest (must be at least one time prior to this filing): In Iowa: Anywhere (specify where and the date): 11. Has an application to register the mark, or portions or a composite of the mark, been filed in the United States Patent and Trademark Office by the applicant or a predecessor in interest? (check one): YES If "YES", please state: Date of filing: Serial Number of application: Status of application: Has application been refused?: Has otherwise not resulted in registration: Reason: 12. If the proposed mark has acquired a secondary meaning so that if the mark would otherwise be unregisterable, it could still be considered for registration, explain how the secondary meaning developed and attach any documents or evidence to support the existence of the secondary meaning. YES YES NO NO NO I certify under penalty of perjury and pursuant to the laws of the state of Iowa that the preceding is true and correct, that applicant is the owner of the mark, that the mark is in use, and that, to the knowledge of the applicant and 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 or in such resemblance to the form as to be likely, when applied to the goods or services of such other person, to cause confusion or mistake, or to deceive. Signed ____________________________________________________ Title __________________________ Date _________________________ NOTES: 1. The application fee is $10.00. Make checks payable to SECRETARY OF STATE 2. The information you provide will be open for public inspection under Iowa Code section 22.11 SECRETARY OF STATE Business Services Division Lucas Building, 1st Floor Des Moines, IA 50319 Phone: (515) 281-5204 FAX: (515) 242-5953 Website: sos.iowa.gov 635_0107 1/15 American LegalNet, Inc. www.FormsWorkFlow.com PAUL D. PATE Secretary of State State of Iowa INSTRUCTIONS for Application for Registration of Mark IT IS IMPORTANT that you read and understand these instructions before you begin to complete the application form. Failure to complete the form correctly or to provide all the requested information will result in the application being returned. If you have any questions please contact 515-281-5204. All items must be completed before the application will be considered. If there is insufficient space on the form to provide all requested information, use additional pages as required, numbering to correspond to the item. Other documents or materials may be attached to the application. In such cases the material or documents should be referenced to the form and clearly marked for ease of identification. Item 1 Print the name of the applicant. If the applicant is other than a natural person, the complete legal name of the business entity must be provided. Item 2 Print the business address of the applicant. Item 3 Check the box that describes the applicant. If "other" is checked, state the type of entity; for example "limited liability company." 3a If the applicant is a corporation or other business entity, print the name of the state in which the entity is incorporated or registered. 3b If the applicant is a partnership or limited partnership, print the name of the state under whose laws the partnership was organized, and the legal name of each of the general partners. Item 4 Describe the type of business engaged in by applicant. Be as specific as possible; e.g. a company in the business of manufacturing and selling track mounted earth moving equipment; or a business to provide dental services to children. Item 5 Describe the goods or services that will carry the proposed mark. Be as specific as possible. Do not just say "clothing," but indicate the type of clothing; e.g. boy's casual clothing, women's sportswear, women's jeans. Item 6 Indicate the class number and the class title of goods or services that will carry the mark. This information can be found on the sheet accompanying the application form, or may be obtained from the Secretary of State by calling 515/281-5204. ONLY ONE CLASS MAY APPEAR ON THE APPLICATION. If multiple classes are sought, each class must appear on a separate application. Item 7 Provide a brief description of the way applicant will use the proposed mark; e.g. as a slogan to introduce or promote the sports section of a TV news program, or as a logo to appear on product packaging. Be specific and include all ways the mark is intended to be used. Item 8 Describe the proposed mark in sufficient detail such that a person who has not seen the mark would be able to comprehend what it looks like after reading the description. The description should include any colors which will be used, any specific fonts applied to words, or any specific designs, shapes or borders. 635_0107 1/15 American LegalNet, Inc. www.FormsWorkFlow.com Item 9 List any word, phrase, design or shape includ