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Application For Cancellation Of A Registered Mark - Connecticut Secretary Of The State

OFFICE OF THE SECRETARY OF THE STATE

MAILING ADDRESS:

DELIVERY ADDRESS:

Commercial Recording Division

Connecticut Secretary of the State

P.O. Box 150470

30 Trinity Street

Hartford, CT 06115-0470

Hartford, CT 06106

860-509-6003

APPLICATION FOR CANCELLATION OF A REGISTERED MARK

Filing Fee: $50.00

Make Checks Payable to “Secretary of the State”

$25.00 for Collective and Certification Marks

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. 12/07/09

Application For Cancellation Of A Registered Mark - Connecticut Secretary Of The State