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

2. Complete name of applicant: *

First

Middle

Last

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.

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

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 *

Email *

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