`
`Declaration
`
`Applicant requests registration of the above—identified trademark/service mark in the United States
`Patent and Trademark Office on the Principal Register established by the Act of July 5, 1946 (15 U.S.C.
`Section 1051 et scq., as amended). Applicant is the owner of the mark sought to be registered, and is
`using the mark in commerce on or in connection with the goods/services identified above, as evidenced
`by the attached specimen(s) showing the mark as used in commerce.
`
`The undersigned, being hereby warned that willful false statements and the like so made are punishable
`by fine or imprisonment, or both, under l8 U.S.C. Section 1001, and that such willful false statements
`may jeopardize the validity of the form or any resulting registration, declares that he/she 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 registered, or, if the form is being filed under 15 U.S.C.
`Section 1l26(d) or (e), he/she believes applicant to be entitled to use such mark in commerce; to the best
`of his/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: /DJ
`
`,
`Signature:
`Signatory‘s Name: /Michae Levy/'
`Signatory's Position: gfi C H9
`
`Date Signed:
`
`NOTE TO APPLICANT: When filed as part of the electronic form (i.e., scanned and attached as an
`image file), the signature page must include both the signature information and the boilerplate
`declaration language. Do not include the entire application, but do ensure that the boilerplate declaration
`language actually appears; a signature by itselfwill not be acceptable. If, due to browser limitations, the
`boilerplate declaration language appears on a previous page when printed, you must "merge“ the
`declaration and signature block onto a single page prior to 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.
`
`http://eteas.uspto.gov/aou/xslt.service?xsl=hsign
`
`l2/29/2009
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