Filing Fee $40.00 MARK STATE OF MAINE APPLICATION FOR ASSIGNMENT Deputy Secretary of State A True Copy When Attested By Signature Pursuant to 10 MRSA �1525, the undersigned hereby applies to the Secretary of State of Maine to assign the following mark: Deputy Secretary of State CAREFULLY READ ALL OF THE INSTRUCTIONS BEFORE YOU COMPLETE THIS FORM. THIS ASSIGNMENT SHOULD BE RECORDED WITH THE SECRETARY OF STATE WITHIN 3 MONTHS A. B. CHARTER NUMBER (if known) ____________________ Amendments to TEXT and FEATURES of the mark are NOT permitted. 1. TEXT - list word(s) protected in the original registration, if any (if none, so indicate): ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 2. FEATURES - describe in detail the design protected in the original registration, if any (if none, so indicate): ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ C. Amendments to Type of Mark must be made on Form No. MARK-3 or, at the time of Renewal, on Form No. MARK-2. TYPE OF MARK: ___________________________ American LegalNet, Inc. www.FormsWorkFlow.com D. ASSIGNOR 1. Assignor Name and Address _______________________________________________________________________________________________ _______________________________________________________________________________________________ 2. Assignor is a (an) ! association ! individual ! union ! general partnership ! limited partnership ! corporation ! other __________________________________________________ (Explain) If a corporation, limited partnership, limited liability company or limited liability partnership the state of incorporation/organization is _____________________________ and the date of incorporation/organization is ________________________ 3. Whereas, I ______________________________________________________________________________ believe (Print/Type Name and Capacity) _______________________________________________________________________________________________ ("Myself", Firm, Association or Corporate Name) to be the owner of the aforesaid mark, and state that for good and valuable consideration, the receipt of which is hereby acknowledged, said owner has sold, assigned and transferred on (date) ____________________ the entire right, title and interest together with the good will of the business in connection with the aforesaid mark to the assignee herein. 4. E. Dated: ________________________ Signature __________________________________________________ ASSIGNEE 1. Assignee Name and Address _______________________________________________________________________________________________ _______________________________________________________________________________________________ 2. Assignee is a (an) ! association ! individual ! union ! general partnership ! limited partnership ! corporation ! other __________________________________________________ (Explain) If a corporation, limited partnership, limited liability company or limited liability partnership the state of incorporation/organization is _____________________________ and the date of incorporation/organization is ________________________ 3. Dated: _________________________ Signature _________________________________________________ (Signature and Capacity) You MUST submit THREE (3) samples of the mark text and/or design with this application. If the mark is to be protected in color, all the samples must be in the appropriate colors. NOTE: Samples may be 3 of the same item, i.e. business cards, letterhead, etc. THE EXECUTION OF AN APPLICATION CONTAINING FALSE STATEMENTS WHICH ONE DOES NOT BELIEVE TO BE TRUE IS PUNISHABLE AS A CLASS D CRIME ACCORDING TO THE MAINE CRIMINAL CODE, 17-A MRSA �453, "UNSWORN FALSIFICATION". SUBMIT COMPLETED FORMS TO: CORPORATE EXAMINING SECTION, SECRETARY OF STATE, 101 STATE HOUSE STATION, AUGUSTA, ME 04333-0101 FORM NO. MARK-4 Rev. 4/16/2001 TEL. (207) 624-7752 American LegalNet, Inc. www.FormsWorkFlow.com Filer Contact Cover Letter To: Department of the Secretary of State Division of Corporations, UCC and Commissions 101 State House Station Augusta, ME 04333-0101 Tel. (207) 624-7752 Name of Entity (s): _______________________________________________________________________ _______________________________________________________________________ List type of filing(s) enclosed (i.e. Articles of Incorporation, Articles of Merger, Articles of Amendment, Certificate of Correction, etc.) Attach additional pages as needed. ________________________________________________________________________ ________________________________________________________________________ Special handling request(s): (check all that apply) Hold for pick up Expedited filing - 24 hour service ($50 additional filing fee per entity, per service) Expedited filing - Immediate service ($100 additional filing fee per entity, per service) Total filing fee(s) enclosed: $ ________________ Contact Information � questions regarding the above filing(s), please call or email: (failure to provide a contact name and telephone number or email address will result in the return of the erroneous filing (s) by the Secretary of State's office) ___________________________________ (Name of contact person) ___________________________________ (Daytime telephone number) ____________________________________________________ (Email address) The enclosed filing(s) and fee(s) are submitted for filing. Please return the attested copy to the following address: ______________________________________________________________________________ (Name of attested recipient) _____________________________________________________________________________________________ (Firm or Company) _____________________________________________________________________________________________ (Mailing Address) _____________________________________________________________________________________________ (City, State & Zip) American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR ASSIGNMENT OF A MARK Be sure to read Chapter 280 (Rules for Marks Registered Under Title 10, Chapter 301-A) and review the list of class numbers for marks (goods and services) before completing the application for as