The Commonwealth of Massachusetts
William Francis Galvin
Secretary of the Commonwealth
One Ashburton Place, Boston, Massachusetts 02108-1512
Trademark / Service Mark Disclaimer
FORM MUST BE TYPED
FORM MUST BE TYPED
(To be filed with registration)
(General Laws Chapter 110H, Section 3)
All information must be completed or this document will not be accepted for filing.
(1) Applicant’s legal name and business address:
a) Individual: ______________________________________________________________________________________
Last
First
Middle
Business address: _________________________________________________________________________________
Number
Street
_________________________________________________________________________________
City
State
Zip
or
b) Business Organization: _____________________________________________________________________________
Business address: _________________________________________________________________________________
Number
Street
_________________________________________________________________________________
City
State
Zip
(2) I hereby disclaim the exclusive right to use the following descriptive, generic or geographically descriptive components of the
mark (describe portion of text or feature disclaimed):
Executed on: _________________________________________________________________________________________
Month
Day
Year
Signature: ____________________________________________________________________________________________
c110hs3disclaimer 10/25/06