Department Of State Bureau Of Corporations And Charitable Organizations Trademark/service Mark Renewal Or Assignment Page 3

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DSCB: 54-1114/1115-3
ASSIGNMENT: Complete Paragraphs 9, 10, 11 & 12
9.
The mark is being assigned with the goodwill of the business connected with its use or with that part
of the goodwill of the business connected with the use of and symbolized by the mark.
10. The mark is hereby assigned to and the name of the assignee of the mark is (if a corporation, also give
jurisdiction of incorporation):
11. The residence, location or place of business of the assignee is:
Number and street
City
State
Zip
County
12. (Strike out if inapplicable): The present assignor is entitled to make the present assignment by virtue of a
previous assignment to the present assignor recorded with the Department of State on
.
Date
Name of Previous Assignor
IN TESTIMONY WHEREOF, the undersigned person
has caused this Application for Renewal of Registration of
Mark/Assignment of Registration of Mark to be executed
this
day of
,
.
Name of Applicant/Assignor
Signature
Title

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