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Individual Application-Principal Register With Declaration
INDIVIDUAL APPLICATION-PRINCIPAL REGISTER WITH DECLARATION
Mark [Mark]
Class Number [Class Number]
TO THE COMMISSIONER OF PATENTS AND TRADEMARKS:
[Name of applicant]
[Business name and address of applicant]
[Residence address of applicant]
[Citizenship of applicant]
The above identified applicant has adopted and is using the trademark shown in the accompanying drawing for [Common, usual or ordinary name of goods] and requests that such mark be registered in the United States Patent and Trademark Office on the Principal Register established by the Act of July 5, 1946.
The trademark was first used on the goods on [Date first used]; was first used in [Type of commerce] commerce on [Date first used in commerce]; and is now in use in such commerce.
The mark is used by applying it to [manner of application, such as the goods or labels affixed to the product]. Five specimens showing the mark as actually used are presented herewith.
DECLARATION
[Name of applicant], being hereby warned that willful false statements and the like so made are punishable by fine or imprisonment, or both, under Section 1001 of Title 18 of the United States Code and that such willful false statements may jeopardize the validity of the application or any registration resulting therefrom, declares that:
1. [He or She] believes [himself or herself] to be the owner of the trademark sought to be registered;
2. To the best of [his or her] knowledge and belief no other person, firm, corporation or association has the right to use the mark in commerce, either in the identical form or in such near resemblance thereto as may be likely, when applied to the goods of such other person, to cause confusion, or to cause mistake, or to deceive;
3. The facts set forth in this application are true;
4. All statements made in this application of [his or her] own knowledge are true and all statements made on information and belief are believed to be true; and
5. These statements were made with the knowledge that willful false statements and the like so made are punishable by fine or imprisonment, or both, under Section 1001 of Title 18 of the United States Code and that such willful false statements may jeopardize the validity of the application or document or any registration resulting therefrom.
Dated: [Date signed]
Signature of applicant Date
Attach designation of domestic representative, if necessary.