Trademark Disclosure Form

**Please Note: Because of funding limitations currently, we are not accepting new applications. Please check back at the end of June 2014. Thank you for your understanding**


This form is for those wishing to protect a Trademark. This can include a logo, tag line or other mark used in commerce.

Please fill out this form as completely as you can and remember to press the “Send” button when finished.

    Your Name:

    Your Address:


    Your Phone # :

    Your Email Address:

    Alternate Contact Name:

    Alternate Contact Address:


    Alternate Contact Phone #:

    Alternate Contact Email:

    Tribal Affiliation:

    What is the best method for contacting you?

    Is your trademark a logo design, a word, or both?

    If it is a logo, please attach a copy of the logo to this form.

    If it is a word, please write out the word or phrase here:

    Do you wish to be listed as the owner of this mark?

    If you selected No, please provide the name and address of the owner of this mark.


    If the owner is a business, provide the type of business:

    Which state, if any, is the business registered in:

    Will the trademark be used as the name of a store (e.g. Walmart), or will it be used as the name of a product (e.g. Pepsi)?

    Have you started using the trademark to advertise or sell your product?

    If yes, please provide the date you started using your mark:

    If yes, please describe the circumstances where you have used your mark:

    Describe the business or product you will be using your mark with. Will you be offering a service (such as auto repair or home cleaning) or a good (such as cell phones or apple pies)? How will people be able to purchase your product? Will you open a store, run a website, etc.? How do you plan to advertise your product?

    If you have started using your mark, please provide images showing the mark in use. For goods please provide pictures of your mark on a label, tag, or packaging for your product, or attached directly to the product. For services please provide a picture of advertising for your product.

    As a requirement for assistance, NAIPEC usually requires that the invention benefit a tribe, tribal business, or the Native American community. Describe how the protection or sale of your work will benefit a tribe or the Native American community.