U.S. Order Form Please complete this order form to request us to arrange preparation of a U.S. TM application on your behalf. You will be contacted if any further information is required. Contact Information (Individual instructing us) First Name: Last Name: Address 1: Address 2: City: State/Province: Zip/Postal Code: Country: Phone: Fax: Email: Applicant Information (Owner of TM) Name: Entity Type: Click on the one appropriate circle to indicate the applicant’s entity type and enter the corresponding information. Individual Country of Citizenship Corporation State or Country of Incorporation Partnership State or Country Where Organized Name and Citizenship of all General Partners Fill in applicant name and address if different from the contact information above, or else leave it blank: First Name: Last Name: Address 1: Address 2: City: State/Province: Zip/Postal Code: Country: Trade Mark Information Indicate if the TM is a typed word or a stylized mark or design ie. logo: Typed word Stylized mark or design Mark: If stylized, enter literal element of mark, if any. You must email a gif or jpg image of the mark to us attmps@TrademarkProtectionServices.com. If the mark is in a foreign language, indiciate the English translation or transliteration: Describe the goods and/or services: Indicate the International Class of Goods and/or Service that relates to your mark 123456789101112131415161718192021222324252627282930313233343536373839404142 You are allowed up to 6 classes (Hold down the Ctrl button to make more than one selection). Note that a separate application must be prepared in respect of each class relating to your mark. Indicate the basis of your filing: Actual use in Commerce or Intent to use Indicate if you are claiming a priority based upon: Foreign Application or Foreign Registration Country: Country: Filing Date: Registration Date: Serial Number: Registration Number: Indicate the date the mark was first used anywhere: (eg. July 1, 1999) Indicate the date the mark was first used in interstate commerce: (eg. July 1, 1999) Describe how the mark is or will be used (i.e., applied to labels, product packaging, advertisments, etc.): Special instructions or inquiries: Payment Terms I acknowledge and agree that registration of my trademark is not guaranteed by the filing of this application. The fee paid does not cover any services that may be required should a trademark opposition be encountered nor does it include additional government fees, if any. Please send your certified check or money order for US$825 by courier made payable to: “Trademark Protection Services” At the following address: 451 Daly Avenue Ottawa, Ontario K1N 6H6 Processing will begin upon receipt of payment. Check here to accept the User Agreement.