Declaration
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`Page 2 of 2
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`The undersigned being hereby warned that willful false statements and the like are punishable by fine or imprisonment,
`or both, under 18 U.S.C. Section 1001, and that such willful false statements and the like may jeopardize the validity of
`this document, declares that he/she is properly authorized to execute this document on behalf of the Owner; and all
`statements made ofhis/hermn knowledge are true and that all statements made on information and belief are believed
`Signature:
`£M‘
`_
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`to be true.
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`r: )3? - O.
`Date Signed:
`Signatory's Name: Parker H. Bagley
`Signatory's Position: Attorney of record
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`' 03—
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`NOTE TO APPLICANT: When filed as part ofthe 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.
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`Back 5
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`http://eteas.uspto.gov/esu/xslt.service?xsl=hsign
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`2/6/2007
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`Declaration
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`Page 2 of 2
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`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 seq., 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 are punishable by fine or imprisonment,
`or both, under 18 U.S.C. Section 1001, and that such willful false statements and the like may jeopardize the validity of
`this document. declares that he/she is properly authorized to execute this document on behalf of the Owner; and all
`statements made flis/her own knowledge are true and that all statements made on information and belief are believed
`to be true.
`, k213/ W , .
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`5
`“i
`g
`Signature:
`0 4O k ’0 7
`{
`Date:
`Signatory's Name: Parker H. Bagley
`Signatory's Position: Attorney of record
`
`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.
`
`Back J
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`http://eteas.uspto.gov/aou/xslt.service?xsl=hsign
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`2/6/2007
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