1. Applicant's First Name:
2. Applicant's Last Name:
3. Business Name (if any):
4. E-mail Address:
6. State of Formation for Business Entity or Citizenship of Applicant:
State of Formation: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Citizen of: United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Argentina Armenia Aruba Ascension Island Australia Austria Azerbaijan Azores Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia Botswana Bouvet Island Brazil British Territory Brunei Darussalam Bulgaria Burkina Burma Burundi Cambodia Cameroon Canada Canary Islands Cape Verde Chad Chile China Christmas Island Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France Gambia Georgia Germany Ghana Gibraltar Grand Cayman Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard/McDonald Isl. Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Madeira Island Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Namibia Nauru Nepal Netherlands Netherlands Antilles New Calendonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Lucia Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Korea Spain Sri Lanka St. Helena Sudan Surinam Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad/Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine U. Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands (U.S.) Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe Other
7. Address:
City:
State/Province:	Zip/Ctry Code:
8. Contact Information (if different):
Address:
City:
State/Province:	Zip/Ctry Code:
9. Day Telephone:
10. Fax:
11. Trademark or Service Mark:
12. Description of Goods (Please describe the goods and services with which your mark is used in connection.)
14. Is this an "Intent to Use" application?  Yes    No      (An "intent to Use" application is one where the trademark or      service mark is not currently in use in the marketplace.)
15. Date of first use anywhere of the trademark or service mark: // (mm/dd/yyyy)
16. Date of first use in commerce: // (mm/dd/yyyy)      (In commerce is when the trademark or service mark is used on      goods in commerce between 2 states or between the U.S. and      a foreign country.)