Document No.

Intellectual Property Office of the Philippines IPOPHL-SOP-BOT-01-F02

Bureau of Trademarks Rev. No. 04
DECLARATION OF ACTUAL USE Issued by: Date:
(Prescribed Form) BOT 22/01/2019

Please check one: [ ] Within three (3) years from filing of ___________________
th
[ ] Within one year from the fifth (5 ) anniversary of the registration of the mark
Registration No. ________________ Date Issued: _________________________
[ ] Within one (1) year from date of renewal
[ ] Registered under Republic Act No.166
th
[ ] Tenth (10 ) anniversary
Registration No.: ___________________ Date Issued: ______________________
th
[ ] Fifteenth (15 ) anniversary
Registration No.: ___________ Date Issued: ________

I, _____________________, of legal age , ___________citizen, with address at ____________________________depose and state under
oath:

1. I am the [ ] applicant for registration

[ ] authorized officer of applicant-corporation
[ ] registrant
[ ] authorized officer of registered owner-corporation
[ ] agent/authorized representative of applicant/registrant

of the mark

2.The mark was accorded

[ ] Application No. ______________ Filing Date : ___________________________
[ ] Registration No. _____________ Reg. Date : ___________________________
[ ] International Reg. No. __________ IR Reg. Date: ____________________
Subsequent Des. Date: __________________
[ ] International Reg. No. ________________ Date of Grant: ____________________________

for the following class/es of goods and/or services:

3 The Mark was first used on x x x (mm/dd/yyyy).
4. The Mark is being used in the Philippines for the following class/es of goods and/or services :

5. The goods are sold and/or services are rendered in the following outlet/s

Name of Outlets Addresses

_______________________ ________________________________________________________________________________
_______________________ ________________________________________________________________________________

6. As proof of actual use, attached are five (5) labels or pictures of the Mark (or pictures of the stamped container visibly or legibly showing
the Mark) or other evidence of use.
7. This affidavit is executed to attest to the truth of the foregoing and for the purpose of complying with the requirements of R.A. 8293 and
the Trademark Regulations.

________________________________
Registrant

By:
________________________
Name/Title

SUBSCRIBED AND SWORN to before me this day of July, 2022 at __________________________.

NOTARY PUBLIC