TMSM – 01 (Rev 10/02) New Jersey Division of Revenue ORIGINAL APPLICATION TO REGISTER A TRADE OR SERVICE MARK This form may be used by applicants seeking to register a State trade or service mark pursuant to NJSA 56. Applicants are responsible for strict adherence to all requirements set forth in State law. 1. Mark Type: (check one; see reverse side for definitions) ___ Trade Mark ___ Service Mark 2. Name and Description of Mark: (list the term that constitutes the mark or, in the case of a design mark, provide a brief description of its appearance) 3. Description Of The Goods Or Services Involved: 4. Classification Number(s): (minimum of one) 5. Applicant Information: a. Name: b. Business Address: c. Applicant is: (check one) ___An Individual ___ Corporation ___ Partnership ___ Other Business Entity d. If applicant is a corporation, partnership or other business entity, list the home state: e. If the applicant is a partnership, list the names of all general partners: 6. Assignee Information: (if applicable, provide assignee name/address) a. Name: b. Address: 7. Dates: Date First Used in New Jersey (must be entered) ____________ Date First Used Elsewhere ____________ 8. Signature(s) and Statement of Ownership: (verification required) The applicant attests that he or she is the owner of the mark, and that the mark is in use in this State, and that, to his or her knowledge, no other person has registered the mark, either with the US Patent and Trade Mark office or with the Treasurer, or has the right to use the mark or a mark in such near resemblance as to be likely, when used in connection with the goods or services of such other person, to cause confusion, or to cause mistake, or to deceive. _______________________________________ (Signature of Applicant, or a Member of the Firm, or an Officer of the Corporation or Business Applying) _______________________________________ (Assignee, if Applicable) ___________________ (Date) ___________________ (Date) Subscribed and sworn to before me, ______________________________, a Notary Public, this ______ day of ___________________ A.D. 20_____. ____________________________________________ (Notary Public) Note: Attach to this application: 1) a drawing of the mark; and 2) three (3) specimens showing the mark as actually used. American LegalNet, Inc. www.USCourtForms.com (Rev 7/05) Information for completing FormTMSM-01 Type or machine print all information except signatures and file application in duplicate. Remittance/Fees: Check or money order signed and made payable to the NJ Division of Revenue must accompany the application. • Base Filing Fee a) $50.00 per filing (includes one classification) b) $50.00 for each additional classifications (add $50.00 to base fee for each additional classification listed) • Premium Service Surcharges: a) $15.00 additional per filing for expedited handling (8.5 business hour processing for items delivered over the counter) b) $100.00 additional per filing for same day service (same day processing for items delivered over the counter) Addresses: Regular service (regular mail) Expedited or same day service ** NJ Division of Revenue PO Box 453 Trenton, NJ 08646-0453 NJ Division of Revenue 225 West State Street, 3rd Floor Trenton, NJ 08608-1001 **Delivery by messenger or in person only; Do not use USPS overnight delivery. Definitions: A Trade Mark is any word, name, symbol or device or any combination thereof, used by a person to identify and distinguish the goods of the person, including a unique product, from those manufactured and sold by others, to indicate the source of the goods, even if that source is unknown. A Service Mark is any word, name, symbol or device or any combination thereof, used by a person to identify and distinguish the services of one person, including a unique service, from the services of others, to indicate the source of the services, even if that source is unknown. THIS FORM SERVES TO SIMPLY FILE WITH THE TREASURER and DOES NOT REPLACE THE NEED FOR COMPETENT LEGAL ADVICE. American LegalNet, Inc. www.USCourtForms.com