Statement of Use

Confirm Use of the Mark in Interstate Commerce in the United States *

Yes, the mark is being used in Interstate Commerce in the United States (please fill in date sections below) in connection with all of the goods/services listed in the application.

Yes, the mark is only being used on the goods/services listed in the "Additional Information" section below. The other goods/services listed in the application are to be deleted in their entirety.

Date of First Use Anywhere *

Enter the date of first use anywhere and the date of first use in Interstate Commerce in m/d/y format (note these are often the same date)

MM

DD

YYYY

Date of First Use in Interstate Commerce *

MM

DD

YYYY

Credit Card Type *

Please select credit card type

Visa

American Express

Mastercard

Discover

Cardholder Name

First Name

Last Name

Credit Card Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Expiration Date *

Please enter credit card expiration date - **PLEASE ENTER "01" in the Day field

MM

DD

YYYY

Credit Card Authorization *

By checking this box you authorize Robert S. Broder, PLLC to charge your credit card the amount above.

Declaration *

By checking this box you the undersigned being hereby warned that willful false statements and the like so made 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 he is properly authorized to execute this Statement of Use on behalf of the applicant; believes applicant to be the owner of the mark sought to be registered; and that all statements made of his own knowledge are true and all statements made on information and belief are believed to be true.