(1) The name of the person applying for such registration, the residence, location or place of business of the applicant, and, if a corporation, the jurisdiction of incorporation, or, if a partnership, the state in which the partnership is organized and the names of the general partners.

(2) The goods or services on or in connection with which the mark is used, the mode or manner in which the mark is used on or in connection with such goods or services and the class in which such goods or services fall.

(3) The date when the mark was first used anywhere and the date when it was first used in this Commonwealth by the applicant or the predecessor in interest.

(4) A statement that the applicant is the owner of the mark, that the mark is in use and that to the knowledge of the person verifying the application no other person has registered, either federally or in this Commonwealth, or has the right to use such mark, either in the identical form thereof or in such near resemblance thereto, as to be likely, when applied to the goods or services of such other person, to cause confusion or to cause mistake or to deceive.

(4.1) Whether an application to register the mark or portions or a composite thereof has been filed by the applicant or a predecessor in interest in the United States Patent and Trademark Office, and, if so, the applicant shall provide full particulars with respect thereto, including the filing date and serial number of each application, the status thereof and, if any application was finally refused registration or has otherwise not resulted in a registration, the reasons therefor.

(5) Such other information necessary to the administration of this chapter as the department may specify by regulation.