Required Information

Today's Date:____________________

Contact Information

Company: _____________________________________________________________

Contact Person:_________________________________________________________

Title: __________________________________________________________________

Type of organization and State where organized (e.g., New York Corporation)

_______________________________________________________________________

Person(s) authorized to sign on behalf of organization:_____________________

_______________________________________________________________________

Address:_______________________________________________________________

_______________________________________________________________________

Phone Number: _______________________ Facsimile: _______________________

E-mail: _________________________________________________________________

Mark Information

Name of Mark(s): _______________________________________________________

Is the mark(s) for a product or a service?

Provide a description of the goods or services that are sold or will be sold under the mark(s). (e.g., a software program and support services for a health insurance billing system.)

________________________________________________________________________

________________________________________________________________________

Has the mark(s) been used with the identified goods/services?

Yes. Date of first use: ________________________
How have you used the mark with the goods or services (e.g., advertising, marketing, on labels attached to the goods and products)?

________________________________________________________________________

________________________________________________________________________

Have you used the mark across state lines?
Yes. Date first used across state lines: _________________________

No. Approximate date expect to use: ________________________

No. This is an "intent-to-use" situation.
When do you expect to start selling the goods or services with the mark:

In the state: _____________________________

Across state lines: ________________________

Have you filed for a registration anywhere else (e.g., state or foreign country)?

Yes. When? ________________________
No. Do you expect to use the mark in another country?

Yes. When? ________________________
No.

Fee received: _________________________ For: ____________________________

Hoffman Warnick LLC

by____________________________________ Date: __________________________

The above-identified person(s) has received a copy of this Initial Client Consultation and Confidentiality Form.

______________________________________ Date: ___________________________
Mark Owner(s)/Applicant(s) Signature