(a) Subject to the limitations set forth in this article, any person who adopts and uses a mark in this state may file in the office of the Secretary of State, on a form to be furnished by the Secretary of State, an application for registration of that mark setting forth, but not limited to, the following information:

(1) The name and business address of the person applying for such registration and, if a corporation, the state of incorporation;

(2) A description of the goods, services, or business in connection with which the mark is used and the mode or manner in which the mark is used in connection with such goods, services, or business and the class in which such goods, services, or business fall;

(3) The date when the mark was first used anywhere and the date when it was first used in this state by the applicant or his predecessor in business; and

(4) A statement that the applicant is the owner of the mark and that no other person has the right to use such mark in this state either in the identical form thereof or in such near resemblance thereto as might be calculated to deceive or to be mistaken therefor.

(b) Every application under this section shall be signed and verified by the applicant or by a member of the firm or an officer of the corporation or association applying.

(c) Every application under this section shall be accompanied by a specimen or facsimile of such mark in triplicate.

(d) Every application for registration under this section shall be accompanied by a filing fee of $30, payable to the Secretary of State.