New York State Department of State Division of Corporations, State Records and Uniform Commercial Code One Commerce Plaza, 99 Washington Avenue Albany, NY 12231-0001 http://www.dos.ny.gov REG NO Original Application to Register a Trademark 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 TRADEMARK, INCLUDING A WRITTEN DESCRIPTION OF DESIGN FEATURES, IF ANY (DO NOT GLUE A FACSIMILE TO THIS FORM) 6. DESCRIBE THE SPECIFIC GOODS BEING PRODUCED ON WHICH THE TRADEMARK IS USED 7. STATE THE MANNER IN WHICH THE TRADEMARK IS PLACED ON THE GOODS, CONTAINERS, ETC. 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 goods 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-0241-f-l-a (Rev. 07/11) (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 “trademark” means any word, name, symbol or device or any combination thereof used by a person to identify and distinguish the goods of such person, including a unique product, from those manufactured and sold by others, and to indicate the source of the goods, even if the source is unknown. General Classes of Goods: Please refer to the classification of goods and services. 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, State Records, One Commerce Plaza, 99 Washington Avenue, Albany, NY 12231-0001. Questions: If you have any questions, 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-0241-f-l-a (Rev. 07/11) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2