JAMES C. KIRKPATRICK STATE INFORMATION CENTER (573) 751-2783 ROBIN CARNAHAN SECRETARY OF STATE STATE OF MISSOURI COMMISSIONS (866) 223-6535 INSTRUCTIONS FOR CERTIFICATE OF CHANGE OF OWNER’S NAME FOR TRADEMARK/SERVICE MARK 1. Fill in the name and address of the person or corporation who originally registered the mark. 2. Fill in the Missouri Registration Number from the Certificate of Registration and the original date of registration. 3. Fill in the new name of the registrant (individual or corporation). 4. The form is to be signed by the officer or authorized party of the registrant. 5. The change of name form is to be notarized. The notary public is to sign the form and also include their embossed or rubber stamp seal on the document. Any additional notary information required by state law is also to be completed by the notary public. 6. The fee for a change of name of a trademark/service mark is $50. All checks or money orders should be made payable to the Director of Revenue. 7. Send a separate check for each change of name application or mark. 8. A certificate will be issued in the new name of the officer or authorized party of the registrant for the remainder of the term of registration. It will be mailed to the officer or authorized party unless otherwise specified. 9. Completed change of name forms and fee should be returned to the Secretary of State’s Office, Commissions, PO Box 784, Jefferson City, MO 65102. 10. If you have any questions regarding the completion of this form, please call our office at (866) 223-6535. TMSM 40A (10/10) PO BOX 784 • JEFFERSON CITY, MISSOURI • 65102 www.sos.mo.gov American LegalNet, Inc. www.FormsWorkFlow.com E PL UN PUL UM N U LL PO URI B US SALUS Robin Carnahan, Secretary of State DIV D AN ED WE FA ID D WE S T ITE State of Missouri I SUPREM MDC CCXX X ESTO LE A Commissions PO Box 784 / 600 W. Main Street, Rm. 322 Jefferson City, MO 65102 Toll-Free (866) 223-6535 or (573) 751-2783 Certificate of Change of Owner’s Name For Trademarks and Service Marks This is to certify that (Original Name of Registrant) of (Address) has changed its name, and that its use of, right to, and interest in the mark which is registered in the State of Missouri, Registration No. , dated , shall hereafter be in the name of (New Name of Registrant) for the remainder of the term of the registration or of the last renewal thereof. By the signature below, the registrant hereby acknowledges and represents that it has filed all filings and/or amendments with the Missouri Secretary of State necessary to effect the referenced name change, and agrees that this change of name does not serve as or complete an assignment of rights to a different entity or owner. (Signature of officer or authorized party of the Registrant) (Title) State of County of On this day of , before me personally appeared , being the person who signed this instrument, who acknowledged that he/she signed it as a free act on his/her own behalf (or on behalf of the identified corporation or other juristic entity with authority to do so). (Signature of Notary Public) Return completed form to: Commissions PO Box 784 Jefferson City, MO 65102 (573) 751-2783 Typed or printed name State of Commissioned for County My Commission Expires Commission # Form TMSM 40 (10/10) American LegalNet, Inc. www.FormsWorkFlow.com