] Document No. 3S | twetecte! Property Ofte ofthe Pitippines | COGENT Bureau of Trademarks Fe No. 04 t Fanaa Tene] a DECLARATION OF ACTUAL US [sr Tot20%7 Within three (3) years from fling/international registration/subsequent designation Please check one: [| {Within one (1) year from the fith (5°) anniversary ofthe registration {| ] Within one (1) year from date of renewal [| Within one (1) year from the fith (5°) anniversary of each renewal { ] Registered under Republic Act No. 188 [4 Tenth (10°) anniversary {J Fifteenth (15") anniversary oflegal age citizen, residing at (rame of declarant) depose and state under oath that: 1. lamthe [| applicant for registration [ ] authorized officer of applicant-corporation [ ] registrant {_} authorized officer of registered owner-corporation {| agentvauthorized representative of applicantregistrant of the mark 2. The mark was accorded [ ] Application No, Filing Date [| Registration No. Registration Date. Renewal Date [| Intemational Reg. No. International Rég_ Date Subsequent Des. Date [| International Reg. No. Date of Grant Renewal Date for the following ciassles of goods andlor services: (Attach addtional sheets, f necessary) 3. The Mark is being used in the Philippines forthe folowing classies of goods andlor services (Attach additonal sheeU, if necessary) 4 The goods are sold andior services are rendered in the folowing outlets: Name of Outlet Address 5. As proof of actual use, attached are labels or pictures of the Mark (or pictures of the stamped container Visibly or legibly showing the Mark) or other evidence of use. 6. This affidavit is executed to attest tothe truth of the foregoing and for the purpose of complying withthe requirements of R.A. 8283 and the Trademark Regulations, as amended Afant SUBSCRIBED AND SWORN TO before me this _ day of NOTARY PUBLIC (ec. No Page No Boek No Senes of