Free Trademark / Service Mark Assignment - Massachusetts

TMA SMA

Filing Fee $50.00

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 Assignment
(General Laws Chapter 110H, Section 7)

FORM MUST BE TYPED

All information must be completed or this document will not be accepted for filing. (1) Registrant's legal 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:

c110hs7 10/26/06

(3) For each class provide the number and class in which such goods or services fall (see attached classification schedule):

(4) Provide the Massachusetts registration date and number:

The above does hereby assign said trademark or service mark and its registration to the following: or b) Business Organization: _____________________________________________________________________________ Business address: _________________________________________________________________________________ Number Street _________________________________________________________________________________ City State Zip a) Individual: ______________________________________________________________________________________ Last First Middle Business address: _________________________________________________________________________________ Number Street _________________________________________________________________________________ City State Zip



Signed under penalty of perjury: By: __________________________________________ Assignor __________________________________________ Title By: _______________________________________________ Assignee _______________________________________________ Title

COMMONWEALTH OF MASSACHUSETTS
Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512

William Francis Galvin

Trademark / Service Mark Assignment
(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