I, __________________, of _________________ apply to be registered as propietor of trade mark __________ and which is represented in the paper annexed hereto.
I desire
that the said trade mark may be registered in respect of the description of
goods following, contained in Class ____, that
is to say, _________________________.
I have
used the said trade mark in respect of said goods for _____ years before the
date of this statement.
The
_______ day of ______, 2002.
(Signature)
Prepared
by Beth Anne Gray J.