The Commonwealth of Massachusetts William Francis Galvin Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512 FORM MUST BE TYPED Trademark / Service Mark Disclaimer FORM MUST BE TYPED (To be filed with registration) (General Laws Chapter 110H, Section 3) All information must be completed or this document will not be accepted for filing. (1) Applicant’s legal 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) I hereby disclaim the exclusive right to use the following descriptive, generic or geographically descriptive components of the mark (describe portion of text or feature disclaimed): Executed on:_ _________________________________________________________________________________________ Month Day Year Signature:_____________________________________________________________________________________________ c110hs3disclaimer 10/25/06 American LegalNet, Inc. www.FormsWorkflow.com