Application Form For Cancellation Of A Registered Mark - State Of Connecticut

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OFFICE OF THE SECRETARY OF THE STATE
30 TRINITY
STREET
P.O. BOX 150470
HARTFORD, CT 06 115-0470
APPLICATION
FOR CANCELLATION
OF A REGISTERED
MARK
Rev. 1211999
. Name of Record Owner:
!. State of Formation of the Owner ifother than a naturalperson.
1. 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.
Date
5.
Name of Signatory
6.
Title of Signatory ifapplicable
7.
Signature

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