DEPARTMENT OF FINANCIAL INSTITUTIONS APPLICATION FOR REGISTRATION OF MARKS Per chapter 132, Wisconsin Statutes Filing Fee is $15.00; make checks payable to Department of Financial Institutions Registration is effective for 10 years. 1. State Full Exact Name of Registrant (Party Registering Mark) ________________________________________________________________________ 2. If registrant is not an individual person, state the nature or structure of the registrant-for example, corporation, bank, Limited Liability Company, association, club, partnership, etc. ________________________________________________________________________ NOTE: If registrant is required to be licensed or registered with any governmental office, attach copies of the most recent registration document. Copies are not necessary if the registrant’s documents are on file with the Corporations Division of the Wisconsin Department of Financial Institutions. For-profit foreign corporations must be qualified to do business in Wisconsin before this registration can be granted. 3. Describe the type of business and/or goods for which this registration will be used: ________________________________________________________________________ 4. State registrant’s residence, location, or place of business. An actual physical site is required, not a post office box. ________________________________________________________________________ 5. State registrant’s mailing address and telephone: ___________________________________________PHONE: (____)_______________ NOTE: The certificate of registration will be mailed to the above address, unless another is listed here: 6. Complete “A” or “B”. A separate application and fee are required for each mark. a. If the mark you wish to register consists of words only, print the word(s) here: __________________________________________________________________ b. If the mark you wish to register consists of words, symbols, pictures, or a combination, with a distinctive appearance, describe the mark clearly with a written description, (what does your mark look like?), and enclose two samples of the mark. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ _______________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 7. The date on which you first use the mark is extremely important. Indicate month and year. Date of First Use: _________________________________________________________ 8. This is _________ an original application or _________ a renewal application. 9. If an attorney or agent is completing this application, please provide the following: Name (Please Print) ________________________________________________________ Business Address __________________________________________________________ _________________________________________________________________________ Telephone (________)______________________________________________________ 10. I, Being Duly Sworn, state that: I am the registrant or duly authorized representative of the registrant; the facts set forth in this application are true; the registrant has the right to the use of the subject of the registration applied for, and that no other person or persons, firm, partnership, corporation, association of union of workers has such right either in the identical form or in any such near resemblance thereto as may be calculated to deceive; that any accompanying originals, copies, photographs, cuts, counterparts, facsimiles, or drawings filed herewith are correct; that the registrant is not required to be licensed or registered by any government office, or if the registrant is required to be licensed or registered, true and correct copies of the most recent license or registration document are attached; or that the registrant is a resident of the United States. Registrant of Agent must sign below in the presence of a Notary Public. Signature of Registrant or Agent: ______________________________________ Print Name as Signed Above: _________________________________________ Title of Party who signed above: _______________________________________ State of ___________________ County of _________________ SUBSCRIBED AND SWORN TO BEFORE ME ON THIS DATE: _________________ Notary Signature: ________________________________________ My Commission Expires on: _________________________________ Notary must Affix Notarial Seal/Stamp Office Location 345 W. Washington Ave., 3rd Floor Madison, WI 53703 Mailing Address Department of Financial Institutions Trademark Records PO Box 7847 Madison, WI 53707-7847 Telephone: (608) 266-8915 American LegalNet, Inc. www.FormsWorkFlow.com