General Company Information ) tobiashistory UNITED STATES MINT OFFICE OF LICENSING OMB Control No. 1525-0013 APPLICATION FOR INTELLECTUAL PROPERTY USE Use this form to apply for a permission/ license to use United States Mint Intellectual Property and related materials other than in connection with products for commercial purposes. Please indicate which, if any, information you provide that you consider to be proprietary. If an agent, please provide this information for both the agent and the licensee. 1. Your Name and Title: 2. Company/Institution Name: 3. Company/Institution Address: City: State: Zip Code: 4. Phone: ( ) 5. Fax: ( 6. E-mail: Website (URL): 7. Type of Company/Institution [ ] Non-Government Business [ ] Government Agency [ ] Educational Institution [ ] Other Non-profit Organization [ ] Other: (Please specify):______________________________ Intellectual Property Requested Please check the United States Mint intellectual property for which you are interested in obtaining permission to license: [ ] “United States Mint®” name [ ] United States Mint banner logo with Mint seal [ ] Color [ ]Black & White [ ] “50 State Quarters®” or “50 State Quarters® Program” name [ ] 50 State Quarters® Logo [ ] Color [ ] Black & White [ ] “United States Mint Proof Set®” name [ ] “United States Mint Uncirculated Coin Set®” name [ ] “United States Mint 50 State Quarters Proof Set™” name [ ] “United States Mint Silver Proof Set™” name [ ] Golden Dollar obverse (front) image with Sacagawea [ ] Other United States Mint program names or images (please specify): Interested in using images or designs of circulating coins or the quarters issued under the 50 State Quarters® Program? Consult the United States Mint Circulating Coin Policy, which governs the use of United States circulating coins or the United States Mint Quarters Design Use Policy, which governs use of the new quarter designs that have been approved by the United States Secretary of the Treasury. Where did you see this image? Please specify. [ ] Print: [ ] Website (URL): [ ] Other: Mint Form 3045 Use of Intellectual Property Requested 1. Please specify what charges will apply for the materials or products that would contain United States Mint intellectual property if approved (e.g. Wholesale price, retail price, donation for fundraiser, promotional giveaway). 2. Have you been approved previously to use intellectual property from the United States Mint? [ ] Yes. If yes, please indicate the date and intellectual property used. [ ] No. 3. Will you use this intellectual property for an educational purpose? [ ] Yes [ ] No 4. Please explain how you will use this intellectual property. Specify use for the applicable media/materials below: Media/Materials Media/Materials Quantity Distribution Territory Language Duration of Channels Distribution Books Brochures Magazines/Print Ads Point of Sales Materials Newsletters Press releases Websites TV Other Materials (Please specify) Mint Form 3045 5. What is the estimated amount of gross revenue (if applicable) that you or your company will receive from the sale of these materials or those that you will offer or distribute as premiums? 6. Please note: This question applies to use of the Golden Dollar obverse image only in connection with distribution of Golden Dollar coins: If applicable, please explain how you will display or use the Golden Dollar obverse image to promote distribution of Golden Dollar coins (please reference material placement, types of promotional materials that you will use United States Mint provided or company produced materials and any other pertinent information): 7. Deadlines: Provide us with your requested deadline. The Office of Licensing will make every effort to accommodate your request in a timely manner. However, processing times will vary depending on the complexity of the request. Please indicate the format you require for images: Privacy Act Notice: The United States Mint uses the information we collect to help us determine whether and in what manner to grant a license or permission to use United States Mint trademarks, copyrighted materials and other United States Mint-controlled matter, and to perform studies and statistical analyses, maintain records, and respond to inquiries. Completing an application for intellectual property licenses and permissions is voluntary, but failing to complete the form and provide all of the information applicable to your request can delay or prevent processing of your application and prevent you from obtaining your requested license or permission. For more details on what we collect(including information from outside sources), additional uses we may make, and our authority to collect this information, please see our Privacy Policy Statement at www.usmint.gov/policy/index.cfm?action=full. The United States Mint estimates it will take approximately 45 minutes to complete this application form. If a valid OMB control number does not appear on this form, you are not required to complete the form. Any comments or suggestions regarding this application form should be sent to the United States Mint, Office of Licensing, 801 9th Street, N.W., Washington DC 20220. Mint Form 3045.