Secretary of State Office 500 E Capitol Ave Pierre, SD 57501 (605) 773-3537 State of South Dakota Emblem Registration Application SDCL 43-44-3 FILING FEE: $75 payable to SECRETARY OF STATE Attach two specimens or facsimiles of the Emblem 1. Applicant: ____________________________________________________________________________________ Address: ___________________________________________ City: ____________________________________ County: ___________________________________ State: __________________ Zip: _____________________ 2. If a Corporation, where incorporated: _______________________________________________________________ 3. If a partnership, list name and address of partner(s): _______________________________________________________________________________________________ Partner Partner Partner Address Address Address City City City State State State ZIP ZIP ZIP _______________________________________________________________________________________________ _______________________________________________________________________________________________ 4. If an association, list name and address of officer(s): _______________________________________________________________________________________________ Officer Officer Officer Address Address Address City City City State State State ZIP ZIP ZIP _______________________________________________________________________________________________ _______________________________________________________________________________________________ 5. Name of Emblem: 6. Description of Emblem: 7. Mode or manner in which the Emblem is used: Emblem Application 07/01/2009 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 8. Date the Emblem was first used by Applicant or Predecessor: a. In the United States: _________________________________________ b. In the State of South Dakota: ___________________________________ *** This section is to be completed in the presence of a Notary Public *** State of _________________________ ) )§§ County of ________________________ ) I, ___________________________________________________ , __________________________________________ (Print Name of Applicant) (Title) of ______________________________________________________________________________________________ (Print Corporation-Partnership-Association) do solemnly swear that the above named applicant is the owner of the Emblem and that no other person has the right to use such Mark in the State of South Dakota either in the identical form thereof or in such near resemblance thereto as might be calculated to deceive or to be mistaken therefor. Dated _________________________________ By: ___________________________________________ (Applicant Signature) ___________________________________________ (Title) Subscribed and sworn to before me this _______ day of ________________________ , 20 _______ . _________________________________ My Commission Expires ______________________________________________ Notary Public (Notarial Seal) Emblem Application 07/01/2009 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com