CANADA TRADEMARK APPLICATION INFORMATION FORM 1. CLIENT INFORMATION: Name: Address: Telephone: Facsimile: 2. CASE REFERENCE: 3.

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1 1. CLIENT INFORMATION: Name: Address: Telephone: Facsimile: 2. CASE REFERENCE: 3. TRADE MARK If it includes a design, please enclose specimens of the mark as used or proposed to be used, e.g. drawings, labels, containers, black and white photographs. 4. LIST OF WARES (GOODS) OR SERVICES List wares/services in association with which the mark has been used or is proposed to be used. Note that Canada has no classification system. Use separate sheet if more space is required.

2 WARES (GOODS): SERVICES: 5. APPLICANT Name: Address: Please check (X) appropriate box: individual corporation partnership* other (please specify on separate sheet) (* If a partnership, list names and addresses on a separate sheet of all partners and show the trading style of the firm.) KEGB 2004 Page 2 of 6 REV. 11/15

3 6. BASIS FOR APPLICATION There may be more than one basis, i.e. different bases for different wares and/or services depending on the facts. Please complete one or more of sections A, B, C and D below, as appropriate. A. use anywhere and application to register in a Convention country a. details of use: Country: Earliest Date: b. details of foreign application Serial No.: Filing Date: Country: Registration No.: Registration Date: (A mark applied for in Canada must be the same as the mark applied for/registered in the home country.) A certified copy of the home registration must be filed before advertisement of the application in the Trade Marks Journal. A translation of the certified copy must be provided if not in English or French. A CERTIFIED COPY OF THE REGISTRATION IS ENCLOSED A CERTIFIED COPY OF THE REGISTRATION WILL FOLLOW B. proposed use in Canada (The mark will not be registered until the mark has been used in Canada.) KEGB 2004 Page 3 of 6 REV. 11/15

4 C. use in Canada: date of first use in Canada: by Applicant: by another party (please specify): D. use in a Convention country and making known in Canada a. details of use Country: Earliest Date: b. date when mark became known in Canada: c. way in which mark became known in Canada: advertisement in publication circulated in Canada television or radio broadcasts received in Canada other (please specify on separate sheet) (If there is more than one basis, i.e. if more than one of the above sections has been completed, indicate on a separate sheet which wares or services correspond to which bases.) 7. IS CONVENTION PRIORITY TO BE CLAIMED: YES NO If yes, please identify the priority application: Serial No.: Filing Date: Country: KEGB 2004 Page 4 of 6 REV. 11/15

5 (The Convention period is six months from the date of filing of the application from which priority is claimed. A priority claim must be made within the six months but can be made separately from the filing of the application. A certified copy is not required.) 8. PREDECESSOR IN TITLE If the application is based on activities of a predecessor in title of the Applicant, please provide the information below. Name of predecessor in title: Address of predecessor in title: 9. LICENSEE Will the mark be used in Canada by any party other than the Applicant? YES NO If yes, please give name and address of such party: Name: Address: 10. MAINTENANCE OF APPLICATION DO take all steps necessary to keep the application in force in the absence instructions to the contrary. of KEGB 2004 Page 5 of 6 REV. 11/15

6 DO NOT take all steps necessary to keep the application in force in the absence of instructions to the contrary. 11. SEARCH Should a registrability search be conducted prior to filing the application? YES NO 12. ADDITIONAL INSTRUCTIONS: Signature: Date: Please mail, or fax completed form along with all the additional application material to: Kirby Eades Gale Baker Intellectual Property 100 Murray St., Suite 500 Ottawa, ON K1N 0A1 P: F: @kirbyip.com KEGB 2004 Page 6 of 6 REV. 11/15