Filing Fee: $50.00 ID No. ___________ STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS Office of the Secretary of State Corporations Division Trademark Section 148 W. River Street Providence, Rhode Island 02904-2615 APPLICATION FOR THE REGISTRATION OF A SERVICE MARK TO BE TYPED-PLEASE READ INSTRUCTIONS BEFORE COMPLETING THIS FORM 1. Name of Applicant _____________________________________________________________________________________________________ 2. (a) Principal business address ____________________________________________________________________________________________ Street _____________________________________________________________________________________________________________________ City/Town State Zip Code (b) Business address in Rhode Island, if any. [To be filled in only if principal business address is not in Rhode Island.] _____________________________________________________________________________________________________________________ Street City/Town State Zip Code 3. State whether applicant is an individual, partnership, corporation, limited liability company, union or association: ________________________________________________________________________________________ 4. If an entity, what is the state of incorporation? _______________________________________________________________________________ 5. Describe mark (1): _____________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ 6. Describe the specific services in connection with which mark is used: _____________________________________________________________ _____________________________________________________________________________________________________________________ 7. Class No. (2) __________________________________________________________________________________________________________ 8. Check how the mark is used. By applying it: ____ in advertisements of the service ____ on documents, wrappers or articles delivered in connection with the service rendered ____ in other fashions, if so specify: _______________________________________________________________________________________ 9. Date of the first use of mark by applicant or predecessor. [If first use of mark was in Rhode Island, use same date in both (a) and (b).] (a) Anywhere ________________________________________________________________________________________________________ (b) In Rhode Island ____________________________________________________________________________________________________ 10. If either of the above first uses was by a predecessor of applicant, state which use or uses were by a predecessor and identify the predecessor. ________________________________________________________________________________________ 11. The applicant is the owner of the mark, the mark is in use, and to the best knowledge of the person verifying the application, no other person has registered in this state or has the right to use such mark in this state either in the identical form thereof, or in such near resemblance thereto, as to be likely, when applied to the goods or services of such person, to cause confusion or to cause mistake or to deceive. ________________________________________________________ Name of Applicant _______________________________________________________ Signature of Applicant or Authorized Representative of Applicant STATE OF _________________________ COUNTY OF _______________________ ________________________________________________________ Title In __________________________, on this ____________ day of ________________________, 20___, personally appeared before me ______________________________________________________, who, being by me first duly sworn, declared that he/she signed the foregoing application in the capacity indicated and that the statements contained therein are true, complete and correct. ________________________________________________________ Notary Public My commission expires: ___________________________________ Form No. T-81 Revised: 03/08 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS AND CLASSIFICATION OF SERVICES FOR REGISTRATION OF A SERVICE MARK Chapter 6-2 of the General Laws of Rhode Island, 1956, as amended A filing fee of $50.00 must accompany the application for the registration of a service mark. Make all money orders and checks payable to the Secretary of State. Send a separate check for each application. This will prevent the return of multiple applications for correction. All blanks are to be completed before the application will be accepted. If the applicant is a partnership, union, corporation, limited liability company or association, fill in the title or the official capacity of the person signing for such entity. Please include three (3) specimens or facsimiles of the mark as actually used with the application on 8 1/2 x 11 inch paper, one specimen per page. DO NOT GLUE, STAPLE OR TAPE. The specimen must demonstrate the nature of the services rendered under the mark or show its use with the product the mark identifies. Return to: Corporations Division Trademark Section 148 W. River Street Providence, Rhode Island 02904-2615 NOTES (1) State here what applicant believes to be the essential features of the mark. Be as clear as possible. Do not state “See attached”. (2) Section 6-2-9 provides for the promulgation of rules and regulations for the determination of classes of service. The following general classes of services are established for convenience of administration of this Chapter but not to limit or extend the applicant’s or registrant’s rights. A single application for registration of a mark may include any or all services upon which the mark is actually being used and which are comprised in a single class. In no event shall a single application include services upon which the mark is being used and which fall within different classes. CLASSIFICATION OF SERVICES CLASS 35 – Advertising; business management; business administration; office functions. CLASS 36 – Insurance; financial affairs; monetary affairs; real estate affairs. CLASS 37 – Building construction; repair; installation services. CLASS 38 – Telecommunications CLASS 39 – Transport; packaging and storage of goods; travel arrangements. CLASS 40 – Treatment of materials. CLASS 41 – Education; providing training; entertainment; sporting and cultural activities. CLASS 42 – Providing of food and drink; temporary accommodation; medical, hygienic and beauty care; veterinary and agricultural services; legal services; scientific and industrial research; computer programming; services that cannot be classified in other classes. American LegalNet, Inc. www.FormsWorkflow.com