(To be made in duplicate)

I, (we) .......

whose full post office address(es) is (are) .......

.......

hereby request you to register in the name of .......

.......

a Timber Mark which I (we) hereby declare is not and was not in use to my (our) knowledge by any person other than myself (ourselves) at the time of my (our) adoption thereof.

The said Timber Mark consists of .......

(description of the Timber Mark).

A drawing of the said Timber Mark is hereunto annexed.

Signed at this day of 19 in the presence of undersigned witnesses: