`
`The undersigned, beingherelpy warned that willful] false statements and the like so made are punishable
`by line or imprisonment, or both, under 18 U.S.-C. Section 1001, and that such willful false statements
`may jeopardize the validity of the form or any resulting registration, declares that helshe is properly
`authorized to execute this form on behalf of the applicant; he/she believes the applicant to be the owner
`of the trademark/service mark sought to be reg1'stered,.or, if the form is being filed under 15 U.S.C.
`Section l126('d) or (e), he/she believes applicant to be entitled to use such mark in commerce; to the best
`ofhis/her knowledge and belief no other person, firm, corporation, or association has the right to use the
`mark in commerce, either-in the identical form thereof or in such near resemblance thereto as to be
`likely, when used on or in connection with the goods/services of such other person, to cause confusion,
`or to cause mistake, or to deceive; and that all statements made of his/her own knowledge are true; and
`that all statements made on information and belief are believed to be true.
`
`. Signature Section:
`
`Signature: _
`Signatory‘s Name: Blake Shapiro‘
`"Signatory‘s Position: .
`
`Date Signed:
`
`NOTE TO APPLICANT: When filed as part of the electronic form (ie, scanned and attached as an
`image file}, the signature pa-ge,must.include both the -signature information and the boilexplate
`'
`declaration ‘language. Do not ineludelthe entire -application, but do ensure that the boilerplate declaration
`language actually appears; a signature by itsegfwill not be acceptable. If, due to browser limitations, the
`boilerplate declaration language appears on -aprevious page when printed, you must "merge" the
`declaration and signature block onto a single page priorto signing, so that the one complete page can be
`scanned to create an acceptable image file. it is recommended that you copy—and-paste the entire text
`form into another document, manipulate the spacing there to move the declaration and signature section
`to a separate page, and then print this new version of the text form to send to the signatory.
`
`bttp://eteas.uspto.gov/esulxslt.service?xs1=l1sign
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