Trademark Or Service Mark Application

TMR SMR The Commonwealth of Massachusetts William Francis Galvin Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512 Filing Fee $50.00 per class 5 year renewal period FORM MUST BE TYPED Trademark / Service Mark Renewal (General Laws Chapter 110H, Section 6) FORM MUST BE TYPED All information must be completed or this document will not be accepted for filing. (1) Applicant's name and business address: or b) Business Organization: _____________________________________________________________________________ Business address: _________________________________________________________________________________ Number Street _________________________________________________________________________________ City State Zip a) Individual: ______________________________________________________________________________________ Last First Middle Business address: _________________________________________________________________________________ Number Street _________________________________________________________________________________ City State Zip (2) The mark is (complete one of the following): a) Words only - If the mark is only words, the words in the mark are (include type style if it is claimed as part of the mark): b) Design Only - If the mark is a design only, describe the design (include colors if they are claimed as part of the mark): c) Words and Design - State the words in the mark (include color and type style if they are claimed as part of the mark) and describe the design: c110hs6 10/26/06 American LegalNet, Inc. www.FormsWorkflow.com (3) For each class provide the number and class in which such goods or services fall (see attached classification schedule): (Anapplicationmayincludemultipleclasses) (4) Provide the Massachusetts registration date and number: (5) Attach a specimen showing actual use of the mark on or in connection with the goods or services. The sample specimen may not be larger than 3" x 3". American LegalNet, Inc. www.FormsWorkflow.com The applicant for renewal is the owner of the mark and hereby asserts that the mark has been and is still in use in Massachusetts and that the attached specimen shows actual use of the mark on or in connection with goods or services in the classification noted herein. I, __________________________________________________________________________________________________ , state that I am the applicant for renewal and declare under penalty of perjury that the foregoing application is true and correct. Executed on: _________________________________________________________________________________________ (Month,Day,Year) Signature: ____________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com COMMONWEALTH OF MASSACHUSETTS Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512 William Francis Galvin Trademark / Service Mark Renewal (General Laws Chapter 110H, Section 6) Registered with WILLIAM FRANCIS GALVIN SecretaryoftheCommonwealth on: ___________________________________________ , 20 _________________ Trademark Section One Ashburton Place, Rm. 1717 Boston, MA 02108 Contact Information ________________________________________________________________ Name ________________________________________________________________ MailingAddress ________________________________________________________________ City/town State ZIP ________________________________________________________________ Telephone Email American LegalNet, Inc. www.FormsWorkflow.com