Flat Fee Trademark Application

Applicant's Name *

If Applicant is an individual please enter first and last name. If Applicant is a corporate entity (i.e., Inc. or LLC) please enter the word "Business" in last name field.

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Type of Entity (i.e. Inc., LLC) or Individual *

Click the appropriate circle to indicate the applicant's entity type. If your entity type is not one of the options displayed directly to the left, you must click on "Other" and describe in the "Additional Information" section below

Individual

Corporation

Limited Liability Company

Other

Applicant's Phone Number *

Please enter Applicant's phone number

(###)

###

####

Has there Been Use of the Mark in the United States *

Yes, the mark is being used in Interstate Commerce (if mark is being used, please skip Intent-to-Use section and fill in the date sections below)

No, the mark is an Intent-to-Use (if mark is not being used please skip date sections) and please check Intent-to-Use certificaion below

Intent-To-Use

If the Application is Intent-to-Use please check the following box

By checking this box Applicant has a bona fide intention to use the mark in commerce on or in connection with the above-identified goods/services. (15 U.S.C. 1051(b), as amended.)

Date of First Use Anywhere

If use has begun in interstate commerce in the United States please 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 in Interstate Commerce

MM

DD

YYYY

Credit Card Type *

Please select credit card type

Visa

American Express

Mastercard

Discover

Credit Card Info

Click here if credit card name and billing address is the same as Applicant's name and address above. If not please enter below.

Click here if credit card name and billing address is the same as Applicant's name and address above.

Credit Card 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 $995 (for a single class application, including filing fee) and understand that there is no guaranty of registration. Note, allowed Intent-to-Use applications will have an additional fee of $495 to file a Statement of Use (SOU) or request for an extension of time to file a SOU.

Power of Attorney *

By checking this box Applicant hereby appoints: Robert S. Broder, PLLC, 1129 Northern Blvd., Suite 404, Manhasset, NY 11030 to prosecute this application to register, to transact all business in the Patent and Trademark Office in connection therewith.

Declaration *

By checking this box you 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 the application or any resulting registration, declares that he/she is properly authorized to execute this application on behalf of the applicant; he/she believes the applicant to be the owner of the trademark/service mark sought to be registered, or, if the application is being filed under 15 U.S.C. 1051(b), he/she believes applicant to be entitled to use such mark in commerce; to the best of his/her knowledge and belief no other person, firm, corporation, or association has the right to use the above identified mark in commerce, either in the identical form thereof or in such near resemblance thereto as to be likely, when used on or in connection with the goods/services of such other person, to cause confusion, or to cause mistake, or to deceive; and all statements made of his/her own knowledge are true and all statements made on information and belief are believed to be true.