Sample

I, __________________, of _________________ apply to be registered as propietor of trade mark __________ and which is represented in the paper annexed hereto.

I desire that the said trade mark may be registered in respect of the description of goods following, contained in Class ____, that  is to say, _________________________.

I have used the said trade mark in respect of said goods for _____ years before the date of this statement.

The _______ day of ______, 2002.

                                                                           (Signature)

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Prepared by Beth Anne Gray J.

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updated 14-Jan-2007