Premier IP Protection, LLC
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Trademark Registration Disclosure Form

This form should be used if you want to register a trademark with the United States Patent & Trademark Office. You may fill-out this form and then return it to us via email by pressing the “submit” button at the end of this form. Alternatively, you may print-out this form, fill-in the requested information and return it to us by U.S. post office mail or facsimile.

* Required Field
*Your Name:
(first, middle, last)
Home Address:
Mailing Address:
City:
City:
State:
State:
Zip:
Zip:
*Home Phone:
Other Phone:
Fax:
*E-mail:
I.
*Provide the name and/or an image of the design of your proposed mark.  If sending an image of the design by email, the design should be in JPG, JPEG, GIF or Pdf format.  You may also send us the image of the design together with this completed form by facsimile.
  OR attach a file from your computer that contains an image of the design, if any:
II.
If you are not now commercially using the mark, provide the date on which you intend to use the mark commercially:
III.
If you are now using the mark, please provide:
 
 
if you are only using the mark solely in intrastate commerce (that is, only within a single state) the date you first used the mark only within that single state and the name of that state (for example, January 1, 2007 only in California)
  if you are using the mark in interstate commerce (that is, in more than one state), the date you first used the mark in interstate commerce
IV.
Have you previously applied for the same or similar mark with the United States Patent & Trademark Office or with a foreign trademark office?
V.
Describe the goods or services to which your mark applies:

Our Assurance of Confidentiality
Premier IP Protection, LLC hereby agrees that any information pertaining to invention(s), idea(s), and the like provided by the owner(s) of the mark named in this Trademark Registration Disclosure Form will not be revealed, used, disclosed, sold, or transferred without the express authorization of the owner(s) of the mark, except if required by court order.

For Premier IP Protection, LLC:
Walter S. Stevens
Walter S. Stevens, Esq.
Manager Member

Trademark Owner's Statement
By submitting this Trademark Registration Disclosure Form and any other information pertaining to the mark, I acknowledge that Premier IP Protection, LLC is accepting this information for review purposes only.  I understand that any comments that I receive based upon this review are based upon a limited analysis and is neither meant nor understood to be a conclusive legal opinion.  Further, I agree that Premier IP Protection, LLC cannot be held responsible for any recommendations based upon the review of the information herein and cannot be held responsible for the return of any submitted materials.  Even if no signature(s) for the owner(s) of the mark is/are included in the submitted form, I/we acknowledge that the submission of this Trademark Registration Disclosure Form shall indicate my agreement to this Trademark Owner’s Statement.

Signature**:
Date

** There is no need sign this form, if returning this form online. It will be assumed that the completed form is from the individual whose name appears above.

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