Statement of Use for Trademark

Applicant Name:
Address:
City:
State:
ZIP Code:
Trademark Name:
Application Serial Number:
Description of Goods/Services:
Date of First Use in Commerce:
Date of First Use Anywhere:
Specimen Description:
Declaration:
I certify that I am using the mark in commerce on or in connection with the goods/services identified above, that the specimen(s) submitted show the mark as used in commerce, and that all statements made of my own knowledge are true. I understand that willful false statements and the like are punishable by fine or imprisonment, or both, under 18 U.S.C. ยง 1001.
Signature:
Name:
Date: