Free Microsoft Word - app for cert of renewal of cert 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 CERTIFICATE OF RENEWAL OF A CERTIFICATION MARK (Can be filed only within 6 months prior to the expiration of a registration) Filing Fee: $50.00 1. Name of Record Owner: 2. State of Formation of the Owner if other than a natural person:

3. New Address of Owner (if applicable):

____________________________________ ____________________________________ ____________________________________ ____________________________________

4. Connecticut Registration Number: ____________________________

The owner of the mark, which is the subject of this application, asserts that the mark has been and is still in use in Connecticut. The owner hereby applies for renewal of the registration bearing the number stated in Number 4 above.

EXECUTION: I hereby declare under the penalties of false statement that the statements made in the foregoing application is true.

5. ___________ Date

6. ________________________________ Name of Signatory

7. ______________________________ Title of Signatory if applicable

8. _________________________________________________________________ Signature

9. The applicant must submit three specimens or photographs of the mark as actually used in this state.

Rev. 08/24/2007