(a) The name and business address of the person filing the statement;
and, if a corporation, the state of incorporation.
(b) The nature of the business of the person filing.
(c) The type of vessels, receptacles and utensils in connection with
which the name, mark or device is used.
The statement shall include or be accompanied by a copy, specimen,
facsimile or counterpart of such name, mark or device in quadruplicate,
together with a filing fee of fifty dollars.