TMSM ­ 05 Rev 10/02 New Jersey Division of Revenue APPLICATION TO CANCEL A REGISTERED TRADE OR SERVICE MARK This form may be used by applicants seeking to cancel a registered State trade or service mark pursuant to NJSA 56. Applicants are responsible for strict adherence to all requirements 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.Signature(s): The undersigned request that the mark be cancelled. _______________________________________ (Signature of Owner, or a Member of the Firm, or an Officer of the Corporation or Business Applying) ___________________ (Date) American LegalNet, Inc. www.USCourtForms.com (Rev 7/05) Instructions for Form TMSM-05 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 1) $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) Addresses: Regular service (regular mail) NJ Division of Revenue Po Box 453 Trenton, NJ 08646-0453 Expedited and same day service ** NJ Division of Revenue 225 West State Street, 3rd Fl. Trenton, NJ 08608-1001 **Delivery by messenger 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.USCourtForms.com