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.)