NOTE: Completion only of Items 1,4, and 5 and l1(a) or 11(b) is required for a search. Complete as much of Items 1 through 10 as possible for an application.

1. Indicate actual Mark and/or attach drawing of Mark:

2. (a) Name and address of owner of Mark:
    (b) If corporation, specify name and title of officer who will sign application:
    (c) State of incorporation and principal place of business:

3. Owner's office and a home phone number and name in case of emergency:

4. Verbal description of the Mark:

5. Specify all goods and/or services identified or to be identified by the Mark with     specificity:

6. Date of first use: ___________________________

7. Place of first use: ___________________________

8. Date of intended use: ________________________

9. Date of first shipment of goods & services: ________________________
    (a) Place of shipment (city and state): ____________________________
    (b) Destination: _____________________________________________

10. Attach four (4) original specimens or facsimiles (labels, letterheads, price tags,       bags, etc.) of the Mark as actually used.

11. (a) Attach a check for $195.00 for Federal trademark search or $395.00 for a            Federal and State search payable to Legal and Patent Search, Inc. (a free            unsigned copy of our attorney's opinion is provided upon request by you or your            attorney).
      (b) To authorize charge card payment, complete the following (Check One):
           [ ] American Express, [ ] Visa, [ ] Optima, [ ] Mastercharge Acct.
Credit Credit No.:__________________________
Billing Name: _____________________________
Expiration Date: _____________________
Billing Address:_____________________________________________________
Phone Number:______________________
Signature: __________________________

Amount Charged: $__________