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Change Of Address For Registered Mark Owner Form - Connecticut 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

OFFICE OF THE SECRETARY OF THE STATE

CHANGE OF ADDRESS FOR REGISTERED MARK OWNER

Filing Fee: $50.00

Make Checks Payable to “Secretary of the State”

$25.00 for Collective or Certification Marks

1. Name of Record Owner:

2. State of Formation of the Owner if other than a natural person:

3. Connecticut Registration Number: ____________________________

4. New Address of Mark Owner:

EXECUTION:

I hereby declare under the penalties of false statement that the statements made in

the foregoing application is true.

5. __________

6. _________________________________

7. _____________________________

Date

Name of Signatory

Title of Signatory if applicable

8. _________________________________________________________________

Signature

Rev. 12/07/09

Change Of Address For Registered Mark Owner Form - Connecticut Secretary Of The State