APPLICATION FOR CERTIFICATE OF NAME CHANGE OF AN APPLICANT OR REGISTRANT A certificate of name change is filed when the name of the owner of the mark has changed and there is no change in the entity type (i.e. corporation, limited liability company, sole proprietor, etc.). (See Form TM3) Item 1 Applicant (owner name and address): The applicant is the individual or entity that owns the mark. If the applicant is a partnership, both individuals must be listed as the owner and both must sign the application before a notary public. Contact person name and address: Name and address of person we may contact with any questions we may have. (Please furnish an email address, if available). Prior name of applicant (prior owner name and address): The prior applicant is the previous name of the individual or entity that owns the mark. Applicant is a: Indicate the entity type and state of jurisdiction or formation as it is on the current certificate of registration. Name change effective date and kind of mark: Indicate the name change effective date. Indicate the registration type of the mark as a trademark or service mark as it is on the current certificate of registration. Identify each trademark or service mark for which the name change is applicable (or attach an exhibit): Indicate the mark(s) on this line. If the mark is comprised of words only, type or write the words here. If the mark also includes a design, symbol or image, attach an exhibit of the mark to the application. An exhibit is a blank piece of paper with an appearance of the mark only without extraneous markings. A non-refundable filing fee of $30.00 made payable to the Treasurer of Virginia is required for each mark affected by the name change. Describe the product or service(s) the mark represents (identifies): Describe the product (trademark) or service(s) provided (service mark) which the mark(s) identifies as it is on the current certificate of registration. Signature of applicant & notary public ­ The application must be signed before a notary public. Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8 Additional assistance can be obtained by calling (804) 371-9051 or at www.scc.virginia.gov/srf. Mailing address: Division of Securities & Retail Franchising, PO Box 1197, Richmond, VA 23218 American LegalNet, Inc. www.FormsWorkFlow.com TM 3 (11/09) COMMONWEALTH OF VIRGINIA STATE CORPORATION COMMISSION DIVISION OF SECURITIES AND RETAIL FRANCHISING CERTIFICATE OF NAME CHANGE OF AN APPLICANT OR REGISTRANT (Please type or print) Applicant/Registrant name and address:___________________________________________________________________ ____________________________________________________________________________________________________ Contact person name and address:________________________________________________________________________ _________________________________Daytime phone: __________________ Fax number:________________________ Prior name of applicant/registrant and address: _____________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Applicant is a:________________________________Applicant's state or jurisdiction of formation:___________________ (entity type i.e. corporation, partnership, etc) Kind of mark (check one): Trademark ___ Service Mark ___ Date name change effective:________________________ Identify each trademark or service mark for which the name change is applicable (or attach an exhibit of the exact mark(s)): ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Describe the product(s) or service(s) the mark represents (identifies):____________________________________________ ___________________________________________________________________________________________________ (NOTE: The certificate must be signed in the name of the applicant, either by the applicant or by a person authorized by the applicant. The certificate must be sworn to by the person who signed the name of the applicant.) Signature:____________________________________________________Date:_________________________________ Signer's Name:________________________________________________Title:_________________________________ (print or type) State of :_____________________________________, County/City of:__________________________________, to-wit: The foregoing certificate was subscribed and sworn to before me by:___________________________________________ on the __________________________ day of __________________________, ____. My Commission Expires:_______________________________ Notary Public:__________________________________ American LegalNet, Inc. www.FormsWorkFlow.com