11 F0023--Page 1 of 4 OFFICE OF THE MISSISSIPPI SECRETARY OF STATE P. O. BOX 136, JACKSON, MS 39205-0136 601-359-1633 Application to Register or Renew Trade and Service Marks Please refer to on-line instructions while completing this form. 1. Please indicate below the type of registration desired (See instructions for definitions) Trademark Service Mark Original Renewal For Renewals Only 2. Mississippi Registration Number Name of owner (person, corporation or other entity) applying for registration 3. Business address of applicant Telephone (area code first) Mailing Address City State ZIP Code Business Email Address:_____________________________________________________________________________ 4. Applicant is a(n) Corporation Partnership Limited Liability Company Other Individual Limited Partnership Limited Liability Partnership State or country of owner For Foreign Corporation, Partnership, Limited Liability Company, Limited Liability Partnership or Other 5. If partnership or other entity, list names and business addresses of general partners, owners and/or managers: Name and address Title Name and address Title Name and address Title F0023 (Rev. 9/2008) American LegalNet, Inc. www.FormsWorkFlow.com F0023--Page 2 of 4 OFFICE OF THE MISSISSIPPI SECRETARY OF STATE P. O. BOX 136, JACKSON, MS 39205-0136 601-359-1633 Application to Register or Renew Trade and Service Marks 6. The goods or services with which the mark is used are: 7. Classification (Use two digit classification number from instructions.) (Submit a separate application and fee for each classification requested.) 8. State how the mark is being used. 9. Date mark was first used anywhere: First used in Mississippi: MM/DD/YYYY MM/DD/YYYY 10. Has the applicant (or predecessor in interest? filed an application to register in the U. S. Patent and Trademark Office covering an area including this state? Yes No If yes, please provide: Serial Number Filing Application Status Application Refused? Yes No Reasons: F0023 (Rev. 9/08) American LegalNet, Inc. www.FormsWorkFlow.com F0023--Page 3 of 4 OFFICE OF THE MISSISSIPPI SECRETARY OF STATE P. O. BOX 136, JACKSON, MS 39205-0136 601-359-1633 Application to Register or Renew Trade and Service Marks 11. Describe in detail, using words, the mark as you want it registered. 12. Attach three 3 specimens or facsimiles of the mark in use. 13. Consent (if applicable). SEE INSTRUCTIONS. If another person or company currently owns this mark, give name and address of owner of existing mark and attach hereto letter of consent. 14. I, the owner of the mark, a member of the firm or an officer of the corporation or association applying, attest that the mark is in use, and that to my knowledge, no other person has registered, either Federally or in this state, or has the right to use such mark, except as provided for in item 13 above, either in the identical form or in such near resemblance thereto as to be like, when applied to the goods or services of such person to cause confusion, or cause mistake or to deceive. Name and Title (Please print name.) Signature (Please keep writing within block.) F0023 (Rev. 9/08) American LegalNet, Inc. www.FormsWorkFlow.com F0023--Page 4 of 4 OFFICE OF THE MISSISSIPPI SECRETARY OF STATE P. O. BOX 136, JACKSON, MS 39205-0136 601-359-1633 Application to Register or Renew Trade and Service Marks ACKNOWLEDGMENT State of County of I, being first duly sworn, depose and say that I am of Title Company/Applicant the applicant herein, and that I make this affidavit and verification subject to the perjury laws on the behalf of Company/Applicant and have the authority to make this affidavit and I have read the above and foregoing application and know the contents thereof, and the facts set herein are true. I, further depose and say that the three specimens filed herein are true and correct. Signature of Applicant Sworn to and subscribed before me this day of , Notary Seal Notary Signature My commission expires F0023 American LegalNet, Inc. www.FormsWorkFlow.com