RECORD TRADEMARK TO COMMISSIONER OF CUSTOMS US Customs Service Commissioner of Customs, Washington, DC 20226 Re: Recordation of Trademark To: The Commissioner I _______________________________ (Name) hereby makes application to record the following trademark with the Department of the Treasury, Bureau of Customs: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ (Describe trademark, giving its registration number and other pertinent data) As a part of this application, applicant submits the following information: 1. Trademark owner ___________________________________________________ _____________________________________________________________________ (include name, complete business address, and citizenship of trademark owner or owners); 2. The goods bearing the recorded trademark are manufactured in ___________________________________________________ (Place of Manufacture) 3. State, as appropriate: There are no foreign persons or business entities authorized or licensed to use the trademark by the trademark owner or _____________________________________ (Name of Person or Entity), is located at _________________________________________ (Principal Business Address) is the only foreign _____________________________________ (Person or Business Entity) authorized to use the trademark. Such ____________________ (Person or Entity) is authorized to use the trademark for the following purposes:______________________ ______________________________________________________________________ 4. State, as appropriate: There are no parent or subsidiary companies or other foreign companies under common ownership or control of the trademark owner that use the above-described trademark or ____________________________________ Company, a subsidiary of _____________________________ (Name of Trademark Owner) uses the above-described trademark abroad for the following purposes: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Enclosed, please find: (A) A status copy of the Certificate of Registration for the above mark certified by the United States Patent and Trademark Office showing title and the name of ___________ ______________________________________________ (Name of Trademark Owner) (B) Five copies of the Certificate; and (C) A check in the amount of $____________ to be applied to the recordation fee for the mark. _________________________ _____________ Signature Date