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To the Commissioner of Patents & Trademarks:
(Address) The above-identified applicant has a bona fide intention to use in commerce the trademark shown in the accompanying drawing for ________________ and requests that said 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 is intended to be used on the goods and packaging therefor and in other ways customary in the trade.
Applicant hereby appoints (Name, Address and Telephone of Appointed Attorney) _________________, as the attorney to prosecute this application to registration, to transact all business in the Patent and Trademark Office connected therewith, and to receive the Certificate of Registration.
(Name) declares that he is the President of applicant _____________________; that he believes that applicant is the owner of the mark sought to be registered and to the best of his knowledge and belief, no other person, firm, corporation, or association has the right to use said mark in commerce, either in identical form or in such near resemblance thereto as may be likely, when applied to the goods or services of such other person, to cause confusion, mistake, or to deceive; that the facts set forth in this application are true; that all statements made herein of his own knowledge are true and that statements on information and belief are believed to be true; and further that 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 any registration resulting therefrom.