DECLARATION

I, (ENTER FULL NAME, PASSPORT NUMBER, MARITAL STATUS, OCCUPATION, FULL DOMICILE) hereby declare:

1) That I am the legal representative of (ENTER FULL COMPANY NAME) a company incorporated and existing under the laws of (ENTER STATE AND COUNTRY OF INCORPORATION);

2) That such company has an industrial facility located at (ENTER FULL DOMICILE OF THE COMPANY), and is therein using the trademark of (ENTER “SERVICIOS” IF SERVICE TRADEMARK, OR “FABRICA” IF MANUFATURE TRADEMARK) “(ENTER TRADEMARK)”, to protect and distinguish (ENTER DESCRIPTION OF WHAT IS TO BE PROTECTED UNDER THE TRADEMARK), in international class (ENTER CLASS NUMBER). I authorize Mr. Henry Lang Wien to appoint any notary public of his choice, including himself, to protocolize literally all pertaining parts of this document.

Dated and signed (ENTER CITY, STATE, COUNTRY OF SIGNATURE), on the day (ENTER DAY) of (ENTER MONTH) of (ENTER YEAR).

(ENTER FULL NAME)
___________
Legal Representative
(ENTER FULL NAME OF COMPANY)

Declared before me on the day (ENTER DAY OF NOTARIZATION) of (ENTER MONTH OF NOTARIZATION) of (ENTER YEAR OF NOTARIZATION).

(ENTER FULL NAME OF NOTARY)
______________________
Notary Public