TM
The Commonwealth of Massachusetts
SM
William Francis Galvin
Secretary of the Commonwealth
One Ashburton Place, Boston, Massachusetts 02108-1512
Trademark / Service Mark Cancellation
FORM MUST BE TYPED
FORM MUST BE TYPED
(General Laws Chapter 110H, Section 9)
All information must be completed or this document will not be accepted for filing.
(1) Applicant’s 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) Written description of the mark:
(3) The number and class in which such goods or services fall (see classification schedule):
(4) Provide the Massachusetts registration date and number:
(5) The Registrant requests cancellation of the (check box):
Trademark
Service Mark
or
Attach a copy of the Superior Court Order of Cancellation
I, _________________________________________________________ , state that I am the applicant or a lawfully authorized
(Name of Applicant / Authorized Representative)
representative of the applicant and declare under penalty of perjury that the foregoing application is true and correct.
Executed on: _________________________________________________________________________________________
(Month, Day, Year)
Signature: ____________________________________________________________________________________________
c110hs9 08/14/07
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