State of Utah DEPARTMENT OF COMMERCE Division of Corporations & Commercial Code Application for State Trademark or Service Mark Registration Non-Refundable Processing Fee: [ ] New Filing $50.00 [ ] Renewal $50.00 File Number: It is the applicant's responsibility to check for conflicts with federally registered trademarks or service marks. Complete all spaces. Submit application in duplicate. For further information see instruction sheet. Attach two (2) samples of the mark on separate pages. Please include one (1) self addressed envelope with application. An approved Trademark is registered for a term of 5 years (U.C.A. 70-3a-305) and must be renewed at least 6 months before expiration (U.C.A. 70-3a-305(2)(a)(i)). 1. Applicant/Owner: List the individual/business entity that will own the Trademark/Service Mark on the name line. Name: ____________________________________________________________________________________ Entity Number (if a registered business): _________________________________________________________ Address: __________________________________________________________________________________ City: _______________________________________________________ State: ________ Zip: ____________ Under penalties of perjury, I hereby certify that I own and have the right to use the trademark or service mark applied for, that to the best of my knowledge it is neither identical to nor deceptively similar to any other registered trademark or service mark, and that the two (2) samples attached to this application are representative of the trademark or service mark. Signature: Title: Date: 2. If applicant is a Corporation or an LLC, the state/country in which applicant was registered: 3. If applicant is a General or Limited Partnership, the state/country in which applicant was organized: ________________________ _____________________________________________ ___________________________________________ General Partner Name: 4. Title of the trademark/service mark: General Partner Name: 5. Please describe the trademark/service mark. This must include a full description of colors, graphics, words, etc, so that the description and the sample are exactly the same: 6. The mode or manner in which the trademark or service mark will be used: 7a. Designate the good or service associated with the mark:(U.C.A. 70-3a-308 product & service list): Please select at least one Goods or Services class that most closely matches the MARK you are registering. You may use this site when designating the good or service: Trademark Acceptable Identification of Goods & Services: 7b. Additional Class Codes: You may register the MARK in more than one class (an additional fee of $25 for each code listed). 8. Date of first use of the trademark or service mark (include month and year): In Utah: Outside Utah: Not been used yet: 9. Has this mark been Federally filed with the United States Patent and Trademark Office? _____Yes _____ No If yes, what is its: Filing Date _________________ Serial Number ____________________________ Current Status ______________ If the mark was refused or has otherwise not resulted in a registration, please list the reason: Under GRAMA {63-2-201}, all registration information maintained by the Division is classified as public record. For confidentiality purposes, you may use the business entity physical address rather than the residential or private address of any individual affiliated with the entity. American LegalNet, Inc. www.FormsWorkflow.com