~To the Commissioner for Trademarks~
<TRADEMARK/SERVICE MARK INFORMATION>
<Mark>
<Registration Number>
<Registration Date>
<OWNER INFORMATION>
<Name>
<Street>
<City>
<State>
<Country>
<Zip/Postal Code>
<Entity Information>
<GOODS AND/OR SERVICES INFORMATION>
<All Goods and/or Services in Existing Registration>~The owner is using the mark in commerce on or in connection with all of the goods and/or services listed in the existing registration. If not, then complete the next section below.~
<Goods and/or Services Not Covered~In the following space, list only those goods and/or services (or entire class(es)) appearing in the registration which are not included in this Declaration. LEAVE THIS SPACE BLANK IF THE OWNER IS USING THE MARK ON OR IN CONNECTION WITH ALL GOODS AND/OR SERVICES LISTED IN THE REGISTRATION).~
<FEE INFORMATION>
~Section 8 Filing Fee~
$100.00 / x <Number of Classes> / = <Filing Fee Due> / $
~Grace Period Fee: If filing during the six-month grace period, enter §8 Grace Period Fee~
$100.00 / x <Number of Classes> / = <Grace Fee Due> / $
~Filing Fee Due + Grace Period Fee Due~ / = <Total Fees Paid> / $
<SPECIMEN AND SIGNATURE INFORMATION>
~The Owner is using the mark in commerce on or in connection with the goods and/or services identified above, as evidenced by the attached specimen(s) showing the mark as currently used in commerce. (You MUST ATTACH A SPECIMEN showing the mark as currently used in commerce for at least one product or service in each international class covered.)
The undersigned being hereby warned that willful false statements and the like are punishable by fine or imprisonment, or both, under 18 U.S.C. §1001, and that such willful false statements may jeopardize the validity of this document, declares that: I am properly authorized to execute this document on behalf of the Owner; all statements made herein of my own knowledge are true; and all statements made on information and belief are believed to be true.
Owner hereby appoints J. Ernest Kenney, Eugene Mar, Richard E. Fichter, Thomas J. Moore, Eric S. Spector, Felix J. D’Ambrosio, and George A. Loud, all with Bacon & Thomas, PLLC as Owner’s attorneys with full powers of association, substitution and revocation, to transact all business in the U.S. Patent and Trademark Office associated with the present document, and to prosecute the present document. Please address all correspondence as stated below.
Owner instructs Bacon & Thomas, PLLC to take instructions regarding the mark from owner’s agent, who transmits this document to Bacon & Thomas, PLLC.~
~ Signature~
<Name>
<Title>
<Date>
<CONTACT INFORMATION>
<Name>
<Company/Firm Name> / BACON & THOMAS, PLLC
<Street> / 625 Slaters Lane, Fourth Floor
<City> / Alexandria
<State> / VA
<Country> / USA
<Zip/Postal Code> / 22314-1176
<Telephone Number> / 703-683-0500
<Fax Number> / 703-683-1080
<e-mail Address> /
<DOMESTIC REPRESENTATIVE>~Required ONLY if Owner’s address is outside the United States.~
<Name> / BACON & THOMAS, PLLC
~is hereby appointed Owner’s representative upon whom notice or process in proceedings affecting the mark may be served.~
<Street> / 625 Slaters Lane, Fourth Floor
<City> / Alexandria
<State> / VA
<Zip/Postal Code> / 22314-1176
(12Sep05)