COMMONWEALTH OF KENTUCKY ALISON LUNDERGAN GRIMES SECRETARY OF STATE Trademark/Service Mark Application Pursuant to the provisions of KRS 365.567 to 365.581, the undersigned hereby makes application for the registration of a mark in Kentucky and for that purpose submits the following statements: 1. The undersigned applicant is an individual (Must check one) a limited liability company a corporation a partnership other organization __________________ 2. The applicant is applying for (Must check one) a trademark registration a service mark registration 3. The name of the applicant: _______________________________________________________________________ 4. The business address of the applicant is: street address ________________________________________________ city________________________________ state ____________________________ zip code __________________ 5. If the applicant is a corporation or limited liability company, indicate the state of incorporation/organization: _________ 6. If the applicant is a partnership, indicate the state of organization: _________________________________________ List the names of the general partners: ______________________________________________________________ (Attach a continuation sheet, if necessary) 7. If applying for a trademark, list the goods offered or sold under the mark. If applying for a service mark, list the services provided under the mark: _________________________________________________________________________ _____________________________________________________________________________________________ 8. The manner in which the mark is used in association with the above goods or services: ________________________ _____________________________________________________________________________________________ _ 9. The class comprising the goods or services: (refer to class listing on page 4) ________________________________ 10. List the dates the mark was first used: (a) anywhere: ________________ (b) in Kentucky: _____________________ 11. Describe the mark (words and/or design) as shown on the attached drawing page (do not draw design on application) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 12. Disclaimer (if applicable*): No claim is made to the exclusive right to use the term____________________________ apart from the mark as shown. *see instructions 13. A drawing of all features of the mark for which ownership is claimed accompanies this application. 14. Three specimens showing actual use of the mark accompany this application. The applicant declares the following: I am the owner of the mark and it is in use in the Commonwealth of Kentucky. To my knowledge no other person has registered, either federally or in this state, or has the right to use the mark in this state in an identical form or in such near resemblance as to be likely, when used on or in connection with the goods or services of the other person to cause confusion or mistake, or to deceive. I am ___________________________________ of ___________________________________________, the applicant herein, being first duly sworn, say that I have read the above application and know the contents thereof, and that the facts set out therein are true, complete and correct. ________________________________________________ Signature ________________________________________________ State of ___________________________ County of __________________________ Subscribed and sworn to before me this __________ day of ______________________, 20 _______. Type or Print Name and Title _________________________________________________ Notary Public (01/12) My Commission Expires: _____________________________ Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Trademark/Service Mark Drawing Page Drawing instructions: The applicant must provide a drawing of the mark in addition to the three specimens showing the actual use of the mark in trade. This drawing is intended to show only that which is claimed in the description of the mark under item 11 on the application. If the mark consists of words, letters or numerals, or any combination thereof, and if the mark is not depicted in a special form, or if this special form is not being claimed as a feature of the mark, the mark may be typed in capital letters on the drawing page. If the mark includes a design, a drawing of the entire proposed mark (in clean, uniform black lines) must be attached to the application. If color is claimed as a feature of the mark, it should be indicated where appropriate on the drawing. Application Check List: ___ The original signed and notarized application ___ Three specimens showing actual use of the mark ___ Drawing page ___ Application processing fee of $10 per class Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for completing the KY Trademark Service Mark Application NOTE: Application must be completed, including the notary section at the bottom. Application must be verified and signed by the Applicant or an authorized agent of the Applicant, whose title must be declared under oath. LINE-BY-LINE INSTRUCTIONS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Indicate entity of Applicant, if "other organization" clarify on line below. Must mark only one box. If applying for both trademark and service mark, must use separate applications. Print name of Applicant, must include any formal corporate ending. Print complete business address. This applies only to corporations and limited liability companies, print state of organization. This applies only to organized partnerships, print state of organization. State the products or services associated with the mark. State the way the mark is used to distinguish and identify the products or services listed in item 7. State the classification, by number, that best represents the products or services listed in item 7. Class listing is on page 4 of this application packet. State the earliest date that the mark was used in trade anywhere and the date first used in Kentucky. NOTE: The mark must be in use in KY prior to registration. State the mark in words exactly as it is to be registered. If the mark involves a symbol, design, or nonstandard typeface and the applicant wishes to claim these features as part of the mark,