(a) Subject to the limitations set forth in this chapter, a person who uses a mark may file in the office of the secretary, in a manner complying with the requirements of the secretary, an application for registration of that mark setting forth, but not limited to, the following information:—

1. (1) the name and business address of the person applying for the registration; and, if a corporation, the state of incorporation, or if a partnership, the state in which the partnership is organized and the names of the general partners, as specified by the secretary,
2. (2) the goods or services in connection with which the mark is used and the mode or manner in which the mark is used on or in connection with the goods or services and the class in which the goods or services fall,
3. (3) the date when the mark was first used anywhere and the date when it was first used in the commonwealth by the applicant or a predecessor in interest, and
4. (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 the commonwealth, or has the right to use the mark either in the identical form thereof or in near resemblance thereto as to be likely, when applied to the goods or services of the other person, to cause confusion, or to cause mistake, or to deceive.