COMMONWEALTH OF KENTUCKY ALISON LUNDERGAN GRIMES SECRETARY OF STATE Trademark/Service Mark Renewal Application Pursuant to the provisions of KRS 365.567 to KRS 365.581, the undersigned hereby makes application for the renewal of registration of a mark in Kentucky and for that purpose submits the following statements: 1. The registration being renewed is a trademark. a service mark. (must check one) 2. The name of the applicant: ______________________________________________________________________________________________ 3. The business address of the applicant: ______________________________________________________________________________________________ Address City State Zip Code 4. If the applicant is a corporation or limited liability company, indicate the state of incorporation/organization: _________ 5. If the applicant is a partnership, indicate the state of organization: __________________________________________ List the names of the general partners: _______________________________________________________________ (Attach a continuation sheet, if necessary) 6. Date of original registration: __________________________ Certificate number: ___________________________ 7. The goods or services on or in connection with which the mark is used:______________________________________ ______________________________________________________________________________________________ 8. The class comprising the goods or services (refer to International Classification list on page three): ________________ 9. Name and description of the mark in words: ___________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 10. The mark has been and is still in use in Kentucky. 11. A specimen showing actual use of the mark accompanies this renewal application. I am ______________________________________________________ of _________________________________________, the applicant herein, being first duly sworn; say that I have read the above renewal application and know the contents thereof, and that the facts set out therein are true, complete and correct. I further say that the specimen filed herewith is true and correct. _________________________________________ Signature _________________________________________ Type or Print Name and Title State of ___________________________ County of __________________________ Subscribed and sworn to before me this __________ day of ______________________, 20 _______. _________________________________________________ Notary Public My Commission Expires: _____________________________ (01/12) American LegalNet, Inc. www.FormsWorkFlow.com 1 Instructions for completing the KY Trademark/Service Mark Renewal Application NOTE: Application must be completed, signed and notarized. Application must be verified and signed by the Applicant or an authorized agent of the Applicant, whose title must be declared under oath in the witness of a Notary Public Line-by-Line Instructions: Must check only one box. If mark is registered as both trademark and service mark, use separate renewal applications. Print name of Applicant, including any business entity ending such as Inc., LLC, LP, etc. NOTE: The mark cannot be renewed to a name other than the owner on file with the Secretary of State unless a name change or assignment is recorded with the Secretary of State. 3. Print the business address of the Applicant. 4. This applies only to corporations or limited liability companies, print state of organization. 5. This applies only to organized partnerships, print state of organization. 6. Print the date that the mark was originally registered with the KY Secretary of State, and most recent certificate number (also known as registration number). NOTE: A single application may contain only a single mark. 7. If applying for a trademark renewal, list the goods offered or sold under the mark. If applying for a service mark renewal, list the services offered under the mark. 8. State the classification, by number, that best represents the product or service listed in item 7. Refer to the class listing on page th 3. NOTE: The KY Secretary of State adopted the international trademark classification schedule as of July 15 1994. Any mark registered prior to that date will be converted to the international classification system upon renewal. If the mark was originally registered or renewed in an inappropriate class, it may be converted to the correct classification upon renewal. The class list that follows is the international schedule of classes. 9. State the mark in words exactly as it is registered, including a brief description of any design element involved. 10. This is a declaration that the mark is eligible for renewal based on continued and current use in the normal course of commerce in Kentucky. 11. Provide one actual specimen of use. NOTE: If the mark has been changed significantly and is no longer in use as registered, or is no longer used in the classification in which it was originally registered, the mark cannot be renewed and a new application will be required to register the new mark. 12. Signing and verifying the application: The applicant must swear under an oath administrated by a notary public that the information is true and correct and must sign the application in the presence of a notary public. 1. 2. SPECIMEN: The application must be accompanied by a specimen showing the mark as actually used. A specimen must show usage in the normal course of trade in the Commonwealth of Kentucky. A trademark specimen may include the following: label, tag, a picture or impression of the mark stamped on, printed on or otherwise applied to the goods. A service mark specimen may include the following: advertisement, brochure or flier. Note: business cards and stationery may be acceptable provided that they show a connection between the mark and the services offered. The specimen must clearly indicate the services. NOTE: Names or marks typed, printed or written on plain paper are not acceptable as specimens of use of the mark. Photo-ready or computer generated print-outs are not acceptable as specimens of use. FILING FEES: The filing fee for Trademark/Service Mark Renewal Application is $5.00 per class. When a single renewal application includes goods or services falling in multiple classes, a fee of