TMSM ­ 04 Rev 05/2012 New Jersey Division of Revenue APPLICATION TO AMEND A REGISTERED TRADE OR SERVICE MARK This form may be used by applicants seeking to amend a registered State trade or service mark pursuant to NJSA 56. Applicants are responsible for strict adherence to all requirements as set forth in State law. 1. Trade/Service Mark Number (as assigned by the Treasurer and listed on the Certificate of Registration): 2. Owner Information: a Name: (must match the name shown on the Division of Revenue's records) b. Business Address: (must match the address shown on the Division of Revenue's records) 3. Amendment Type: (check all that apply) _____ Owner Name Change _____ Owner Address Change _____ Classification Change Note: This form may not be used to assign ownership --use Assignment Form TMSM-03 for assigning ownership of a registered mark. Also, an amendment shall not include alterations to the mark name or drawings/ facsimiles associated with the original filed application. 4. Details of Change: (indicate new name, new address, and/or instruction to add/delete a classification) 5. Signature(s): The mark is hereby amended. __________________________________ (Signature of Owner, or a Member of the Firm, or an Officer of the Corporation or Business Applying) ____________________ (Date) American LegalNet, Inc. www.FormsWorkFlow.com (Rev 05/2012) Instructions for Form TMSM-04 Type or machine print all information except signatures and file the application in duplicate. Remittance/Fees: A check or money order signed and made payable to the NJ Division of Revenue must accompany the application. Base Filing Fee $50.00 per filing (includes one classification) Premium Service Surcharges: 1) $15.00 additional per filing for expedited handling (8.5 business hour processing for items delivered over the counter) 2) $100.00 additional per filing for same day service (same day processing for items delivered over the counter) Regular service (regular mail) NJ Division of Revenue PO Box 453 Trenton, NJ 08646-0453 Expedited and same day service ** NJ Division of Revenue 33 West State Street, 5th Fl. Trenton, NJ 08608-1214 Attn: TMSM Unit **Delivery by courier service or in person only. Do not use USPS overnight delivery. THIS FORM SERVES TO SIMPLY FILE WITH THE TREASURER and DOES NOT REPLACE THE NEED FOR COMPETENT LEGAL ADVICE. American LegalNet, Inc. www.FormsWorkFlow.com