NYS DEPARTMENT OF STATE MISCELLANEOUS RECORDS One Commerce Plaza, 99 Washington Avenue Albany, NY 12231-0001 http://www.dos.state.ny.us REG NO Original Application to Register a Servicemark Please read the instructions prior to completing this form; attach additional sheets as needed. 1. APPLICANT NAME 2. ADDRESS NUMBER AND STREET CITY STATE ZIP 3. IF A CORPORATION, ENTER STATE IN WHICH INCORPORATED AND IF A PARTNERSHIP, ENTER STATE IN WHICH ORGANIZED 4. IF A PARTNERSHIP, LIST THE NAMES OF ALL GENERAL PARTNERS 5. DESCRIBE THE SERVICEMARK, INCLUDING A WRITTEN DESCRIPTION OF DESIGN FEATURES, IF ANY (DO NOT GLUE A FACSIMILE TO THIS FORM) 6. STATE THE SPECIFIC SERVICES FOR WHICH THE MARK IS USED 7. DESCRIBE THE MODE OR MANNER IN WHICH THE MARK IS USED 8. CLASS NUMBER(S) FOR OFFICE USE ONLY 9. DATE OF FIRST USE (A) IN NEW YORK STATE (B) ANYWHERE The applicant is the owner of the mark, the mark is in use, and, to the knowledge of 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 near resemblance as to be likely, when applied to the services of such other person, to cause confusion, or to cause mistake, or to deceive. The undersigned applies to register the aforesaid mark pursuant to Article 24 of the General Business Law and affirms under the penalties of perjury that the statements herein made, including any attached papers, are true. (Corporation, Association, Firm, etc.) By: (Signature and Title of Officer) DOS-0246-f-l-a (Rev. 08/10) (Date) American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 Instructions: Please refer to the instruction sheet for completion of items 1 through 9 of the registration form. Definition: The term “servicemark” means 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, and to indicate the source of the services, even if the source is unknown. Titles, character names used by a person, and other distinctive features of radio or television programs may be registered as servicemarks not withstanding that they, or the programs, may advertise the goods of the sponsor. General Classes of Services: Class Title Class Title 35 36 37 38 Advertising and Business Insurance and Financial Construction and Repair Communication 39 40 41 42 Transportation and Storage Material treatment Education and Entertainment Miscellaneous Please note there is a $50 filing fee for EACH CLASSIFICATION claimed for registration. Application Form: The application must be on a current form supplied by the Department of State and be completed in the English language and plainly written or typed. If the mark or any part thereof is not in the English language, it must be accompanied by a sworn, notarized, translation. Specimens of the Mark: The application must be accompanied by three specimens (examples) showing the mark as actually used. Specimens are not to be stapled or glued to the form. Mail to: Please mail the completed application form together with the filing fee and three specimens of the mark to: New York State Department of State, Miscellaneous Records Unit,1 Commerce Plaza, 99 Washington Avenue Albany, NY 12231-0001. Questions: If you have any questions or require assistance completing this form, please write to the Department of State, Miscellaneous Records Unit at the above address or call (518) 474-4770. Payment: Checks or money orders should be made payable to the “Department of State.” Please do not send cash through the mail. DOS-0246-f-l-a (Rev. 08/10) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2