OFFICE OF THE SECRETARY OF THE STATE MAILING ADDRESS: Commercial Recording Division Connecticut Secretary of the State P.O. Box 150470 Hartford, CT 06115-0470 860-509-6003 DELIVERY ADDRESS: Commercial Recording Division Connecticut Secretary of the State 30 Trinity Street Hartford, CT 06106 860-509-6003 APPLICATION FOR CERTIFICATE OF RENEWAL OF A COLLECTIVE MARK (Can be filed only within 6 months prior to the expiration of a registration) Filing Fee: $50.00 Make Checks Payable To “Secretary of the State” 1. Name of Record Owner: 2. State of Formation of the Owner if other than a natural person: 3. New Address of Owner (if applicable): ____________________________________ ____________________________________ ____________________________________ ____________________________________ 4. Connecticut Registration Number: ____________________________ The owner of the mark, which is the subject of this application, asserts that the mark has been and is still in use in Connecticut. The owner hereby applies for renewal of the registration bearing the number stated in Number 4 above. EXECUTION: I hereby declare under the penalties of false statement that the statements made in the foregoing application is true. 5. ___________ Date 6. ________________________________ Name of Signatory 7. ______________________________ Title of Signatory if applicable 8. _________________________________________________________________ Signature 9. The applicant must submit three specimens or photographs of the mark as actually used in this state. Rev. 08/24/2007 American LegalNet, Inc. www.FormsWorkflow.com OFFICE OF THE SECRETARY OF THE STATE MAILING ADDRESS: Commercial Recording Division Connecticut Secretary of the State P.O. Box 150470 Hartford, CT 06115-0470 860-509-6003 DELIVERY ADDRES: Commercial Recording Division Connecticut Secretary of the State 30 Trinity Street Hartford, CT 06106 860-509-6003 CERTIFICATE OF RENEWAL OF A COLLECTIVE MARK Filing Fee: $50.00 Make Checks Payable To “Secretary of the State” 1. Name of Applicant/Owner: (Partnerships: attach an 8 1/2 X 11 list of all general partners) 2. Address of Owner of Mark: (Corporations and Partnerships: include state of incorporation or formation) 3. Connecticut registration number: 4. Full description of the mark: 5. Use the space provided for any disclaimers or additional pertinent information regarding the mark. 6. The goods or services on or in connection with which the mark is used: 7. Date on which mark was first used anywhere: 8. Date on which mark was first used in Connecticut: 9. Have applications to register the mark or portions or composites thereof been filed in the United States Patent Office? 10. If No. 9 was answered "YES", indicate filing date, serial number, status, and if registration was refused, the reasons for such refusal: The applicant asserts that the mark is not known to be the subject matter of an existing federal registration granted to another and to the best of the applicant's knowledge, no other person has the right to use such mark in this state either in the identical form thereof or in such near resemblance thereto as to be likely, when applied to the goods or services of such other person, to cause confusion, or to cause mistake or to deceive purchasers. The applicant hereby declares under the penalties of false statement that the statements made in the foregoing application are true. 11. Date: 12. Name of Signatory and Title: (if applicable) 13. Signature: 14. Applicant must submit three specimens or photographs of the mark as actually used in this state. Said specimens or photographs should not be attached by the applicant to the application. Rev. 08/24/2007 American LegalNet, Inc. www.FormsWorkflow.com