Instruction Sheet for the Registration of Trademark

TRADE MARK ACT (CAP. 257) INSTRUCTION SHEET FOR REGISTRATION OF A TRADE MARK

Kindly fill out and return to us:

1. The exact wording, specimen and description or name of the trade mark:

2. Complete name of applicant: *

First

Middle

Last

3. Applicant’s physical and postal address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

4. Citizenship of applicant or state or country of incorporation of applicant

5. Description of goods or services to be protected (must be specific) and, if in an international class or classes please specify:

6. Identify the manner in which the mark is or will be affixed to the goods or how it is or will be used in connection with the services.

7. Indicate if the mark has been used in commerce in Belize.

Yes
No

8. If yes, indicate date of first use (include date , month and year) in Belize.

9. Indicate if the mark has been used outside of Belize. Where? What time period?

10. Name and address of agent in Belize: GLENN D. GODFREY & co. LLP of 35Barrack Road, Belize City, Belize, Central America.

11. Appointment of agent (fill out attached agent form and return to us)

12. Compulsory address for service in Belize is agent’s address:35 Barrack Road, Belize City, Belize, Central America.

13. Include six copies, original form of specimen clearly showing the mark as it appears on the goods or with the service.

14. Indicate whether the trade mark is being used in Belize, by the applicant or withits consent, in relation to those goods or services, or that it has a bonafide intention that it should be so used:

15. I/We

hereby declare that our intentions for registering the trademark herein is bonafide.

Signature *

16. Please note that a trademark that has been registered in Belize may be declaredinvalid because it is identical to an earlier trademark which is protected, that is atrademark that enjoys priority under the Paris Convention 1883.