Page 1 of 2
DOS-0241-f-l-a (Rev. 04/14)
New York State Department of State
Division of Corporations, State Records and Uniform Commercial Code
One Commerce Plaza, 99 Washington Avenue
Albany, NY 12231-0001
REG NO
Original Application to Register a Trademark
Please read the instructions prior to completing this form; attach additional sheets as needed.
1. APPLICANT NAME
2. ADDRESS NUMBER AND STREET CITY STATE ZIP
3. IF A CORPORATION, ENTER STATE IN WHICH INCORPORATED AND
IF A PARTNERSHIP, ENTER STATE IN WHICH ORGANIZED
4. IF A PARTNERSHIP, LIST THE NAMES OF ALL GENERAL PARTNERS
5. DESCRIBE THE TRADEMARK, INCLUDING A
WRITTEN
DESCRIPTION OF DESIGN FEATURES, IF ANY (DO
NOT
GLUE A FACSIMILE TO THIS FORM)
6. DESCRIBE THE SPECIFIC GOODS BEING PRODUCED ON WHICH THE TRADEMARK IS USED
7. STATE THE MANNER IN WHICH THE TRADEMARK IS PLACED ON THE GOODS, CONTAINERS, ETC.
8. CLASS NUMBER(S) 9. DATE OF (A) IN NEW YORK STATE (B) ANYWHERE
FIRST USE
FOR OFFICE USE ONLY
The applicant is the owner of the mark, the mark is in use, and, to the knowledge of the person
verifying the application, no other person has registered, either federally or in this state, or has the
right to use such mark either in the identical form or in such near resemblance as to be likely, when
applied to the goods of such other person, to cause confusion, or to cause mistake, or to deceive.
The undersigned applies to register the aforesaid mark pursuant to Article 24 of the General
Business Law and affirms under the penalties of perjury that the statements herein made, including
any attached papers, are true.
(Corporation, Association, Firm, etc.)
By:
(Signature and Title of Officer) (Date)
http://www.dos.ny.gov
