POWER OF ATTORNEY FORM

Name of Attorney Requesting Caribbean TM Assistance

Requesting Attorney's Telephone

Requesting Attorney's Fax

Name of Proprietor of TM

Address or Proprietor of TM

State or Country of Incorporation of Proprietor

Name of Incorporation of Proprietor

Email Address

Class or Classes of the Subject TM

Description of Goods/Services to be covered by the Subject TM

Year of first use of the Subject TM anywhere in the World

Which jurisdiction(s) do you wish to register the Subject TM?

Anguilla

Antigua

Aruba

Bahamas

Barbados

Belize

Bermuda

British Virgin Islands

Caribbean Netherlands

Cayman Islands

Costa Rica

Cuba

Curaçao

Dominica

Dominican Republic

Grenada

Guyana

Haiti

Jamaica

Montserrat

Puerto Rico

St. Kitts

St. Lucia

St. Maarten

St. Vincent

Suriname

Trinidad & Tobago

Turks & Caicos

U.S. Virgin Islands

Special notes:

Palm Beach Office
George C.J. Moore, P.A.
2855 PGA Boulevard
Palm Beach Gardens, Florida 33410

Telephone: USA 1(561) 833-9000
Facsimile: USA 1(561) 833-9990
Email: IP@caribbeantrademarks.com

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