Free Microsoft Word - app for cancel of a registered mark.DOC - Connecticut

OFFICE OF THE SECRETARY OF THE STATE MAILING ADDRESS: Commercial Recording Division Connecticut Secretary of the State P.O. Box 150470 Hartford, CT 06115-0470 860-509-6003 DELIVERY ADDRESS: Commercial Recording Division Connecticut Secretary of the State 30 Trinity Street Hartford, CT 06106 860-509-6003

APPLICATION FOR CANCELLATION OF A REGISTERED MARK Filing Fee: $25.00 Make Checks Payable to "Secretary of the State"

1. Name of Record Owner: ________________________________________________________________ 2. State of Formation of the Owner if other than a natural person: _________________________________________________________________ 3. Connecticut Registration Number: _________________________________________________________________ The above owner hereby applies for cancellation of the registration bearing the number stated in item number 3 above EXECUTION: I hereby declare under the penalties of false statement that the statements made in the foregoing application is true.

4. __________ 5. _________________________________ 6. ______________________________ Date Name of Signatory Title of Signatory if applicable

7. _________________________________________________________________ Signature

Rev. 08/24/2007