T- For Office Use Only Registration Number APPLICATION FOR REGISTRATION OR RENEWAL OF TRADEMARK OR SERVICE MARK STATE OF NORTH CAROLINA Pursuant to N.C.G.S. §80-3 and §80-5 the undersigned hereby makes application for the registration or renewal of a Trademark or Service Mark and submits the following information: 1. The application is for: ____ Initial Registration - $75.00 (Fees are non-refundable) ____ Renewal - $35.00 (Fees are non-refundable) Registration No. T - ____________ OWNER/APPLICANT INFORMATION 2. Name of Owner/Applicant of the Mark (Individual or Business Entity):________________________________________ _______________________________________________________________________________________________ 3. The undersigned Owner/Applicant is: (Must check one box only and the selection must match the information in #2) an individual a union a sole proprietorship an association a government a corporation or limited liability company (LLC), indicate the state of incorporation or organization: _______________________________________________________ a partnership, indicate the state of organization: __________________________________________________ List the names of the general partners: _________________________________________________________ (Attach a continuation sheet, if necessary) 4. Owner/Applicant Business Address: __________________________________________________________________________ Contact Name: ________________________________________________________________ Attorney : Yes _____, No _____ Contact Mailing Address:___________________________________________________________________________________ Telephone:__________________________Contact E-mail: _______________________________________________________ [You can register only one type of mark per application, a Trademark OR a Service Mark] 5. For Trademarks (Only if producing a product or good) The principal place of business or distribution in this State. ______________________________________________ Address ______________________________________________ City State Zip Check as many as apply The Trademark is applied: _____ Directly to the goods; _____ Directly to containers for the goods; _____ To tags/labels affixed to the goods; or _____ By displaying it in physical association with the goods in sale or distribution thereof 6. For Service Marks (Only if providing a service) The physical location where services are being rendered or offered in this State. _________________________________________________ Address ________________________________________________ City State Zip Check as many as apply The Service Mark is applied: In advertisements of the service; _______ On documents, wrappers or articles delivered in connection with the services rendered; or In the following specified manner: ________________________________ ________________________________ American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR TRADEMARK OR SERVICE MARK REGISTRATION & RENEWAL Page 2 7. SPECIMENS: Pursuant to N.C.G.S. § 80-3.1(b) ". . . The application shall be accompanied by three (3) specimens of the mark as currently used . . . ." Accordingly, please submit three (3) complete, original (no photocopies or "camera ready art"), current (no more than six [6] months old) specimens of the mark as it actually and currently is being used on the goods or to advertise the goods and/or services to the public. See the attached instructions for additional information regarding acceptable specimens. PLEASE NOTE: If the mark "as currently used" is a Design Mark that contains color(s) and you indicate in number 8 below that you do not want to claim and register the Design Mark in color(s), you MUST submit two (2) additional depictions of the colored Design Mark in black and white. (Original black and white photographs of the colored Design Mark are acceptable) MARK INFORMATION [You can register only one type of mark per application] 8. Check the appropriate box to indicate whether you want to register a "Standard Character Mark" OR a "Design Mark" " Standard Character Mark" (aka: Word Mark or Typed Mark) A Standard Character Mark consists only of words, numbers, common punctuation or diacritical marks, but it does not contain a design element or underlining. The mark also can be in any stylized font, size or color, but "NO CLAIM" of such can be made on the application. Read the attached instructions and go to http://teas.uspto.gov/standardCharacterSet.html to review the USPTO's list of acceptable characters. Write the "Standard Character Mark" you wish to register: ____________________________________________________________________________ _____________________________________________________________________________________________________ "Design Mark" A "Design Mark" contains design elements. The design can be a symbol, a hand-drawn design, a graphically created design, or words and a design. When registering a Design Mark, you can claim the color(s), if any, depicted in the mark or elect to not claim the color and register the mark in black and white. Do you want to claim and register the color(s) depicted in the mark: Yes ____ No ____ Describe the Mark: If you are claiming the color(s), provide a detailed description of the mark and identify the color(s) where they appear in your mark. If you are not claiming the color(s) and wish to register the mark in black and white, describe the mark without reference to color(s); attach additional pages if necessary: _____________________________________________________ ____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 9. Describe the specific goods or services in connection with which the mark is used. Please refer to the International C