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BRITISH VIRGIN ISLANDS
STATEMENT ON APPLICATION FOR REGISTRATION OF ONE TRADE MARK

I/We, ,
of, hereby apply to be registered as proprietor of the following trade mark:



I/We desire that the said trade mark may be registered in Class ,in respect of the following description of goods:

I/the said company have used this Trade Mark in respect of the goods mentioned for years before the date of this statement, OR

I /the said company have not previously been used by this trade mark in respect of the goods mentioned but it is now intended to be used.



This is the Statement referred to in the attached signed Declaration.

Executed this day of , 20 .

By:
Name:
Title: