Trademark Or Service Mark Cancellation

TM SM The Commonwealth of Massachusetts William Francis Galvin Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512 FORM MUST BE TYPED Trademark / Service Mark Cancellation (General Laws Chapter 110H, Section 9) 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: a) Individual: ______________________________________________________________________________________ Last First Middle Business address: _________________________________________________________________________________ Number Street _________________________________________________________________________________ City State Zip or b) Business Organization: _____________________________________________________________________________ Business address: _________________________________________________________________________________ Number Street _________________________________________________________________________________ City State Zip (2) Written description of the mark: (3) The number and class in which such goods or services fall (see classification schedule): (4) Provide the Massachusetts registration date and number: (5) The Registrant requests cancellation of the (check box): Trademark Service Mark or Attach a copy of the Superior Court Order of Cancellation I, _________________________________________________________ , state that I am the applicant or a lawfully authorized (Name of Applicant / Authorized Representative) representative of the applicant and declare under penalty of perjury that the foregoing application is true and correct. Executed on: _________________________________________________________________________________________ (Month, Day, Year) Signature: ____________________________________________________________________________________________ c110hs9 08/14/07 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 Cancellation (General Laws Chapter 110H, Section 9) Cancelled with WILLIAM FRANCIS GALVIN Secretary of the Commonwealth on: ________________________ , 20 ___________________________________ Trademark Section One Ashburton Place, Rm. 1717 Boston, MA 02108 Contact Information _______________________________________________________________ Name _______________________________________________________________ Mailing Address _______________________________________________________________ City/town State ZIP _______________________________________________________________ Telephone Email American LegalNet, Inc. www.FormsWorkflow.com