PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Mark Used With Articles or Supplies (54 Pa.C.S.) Application for Registration (§ 1511) Application for Amendment (§ 1512) Document will be returned to the name and address you enter to the left. Name Address City State Zip Code Fee: $50 In compliance with the requirements of the applicable provisions (relating to registration/amendment of articles or supplies), the undersigned desiring the register/amend its mark used in this Commonwealth to indicate the ownership of articles or supplies, hereby states that: 1. The name of the applicant is (if a corporation, also give jurisdiction of incorporation): 2. The residence, location or place of business of the applicant is: Number and street City State Zip County Application for Registration: complete paragraph 3 3. The name, mark or device to be registered is (a facsimile of the mark to be registered accompanies this application as Exhibit A and is incorporated herein by reference): Application for Amendment: complete paragraph 4 4. The last preceding filing with respect to this mark was made in the Department on at . Roll and Film , Date American LegalNet, Inc. www.FormsWorkFlow.com DSCB:54-1511/1512– 2 5. The nature of the business of the applicant is: 6. The type of articles or supplies in connection with the mark is used are: Application for Amendment: complete paragraphs 7 and 8 7. Check one of the following: The foregoing statements revise any information set forth in the preceding filing which has become inaccurate and restate in full such information as so revised. The amendment adopted to revise any information set forth in the preceding filing which has become inaccurate and to restate in full such information as so revised is as follows: 8. The amendment adopted to revise any information set forth in the preceding filing which as become inaccurate and to restate in full such information as so revised is set forth in full in Exhibit B attached hereto and made a part hereof. IN TESTIMONY WHEREOF, the undersigned person/organization has caused this Application to be executed this day of , . Name of Applicant/Applicant Organization Signature Title American LegalNet, Inc. www.FormsWorkFlow.com Department of State Bureau of Corporations and Charitable Organizations P.O. Box 8722 Harrisburg, PA 17105-8722 (717) 787-1057 web site: www.dos.state.pa.us/corps Instructions for Completion of Form: A. Typewritten is preferred. If not, the form shall be completed in black or blue-black ink in order to permit reproduction. The filing fee for this form is $50 made payable to the Department of State. B. The name of a commercial registered office provider may not be used in Paragraph 2 in lieu of an address. C. A mark is “used in this Commonwealth” when the name, mark or device is produced upon articles or supplies which are loaned, rented, sold or otherwise circulated in this Commonwealth. D. A mark is “produced upon” articles or supplies when it is branded, stamped, stenciled, engraved, etched, blown, embossed, impressed, embroidered, sewn or otherwise permanently placed upon any articles or supplies. E. The term “mark” means any word, name, symbol, design or device, or any combination thereof. F. A mark may be registered on this form if it is produced upon any item which is designed and intended for reuse in the normal course of trade by the registrant and includes items such as towels, coats, aprons, uniforms, toilet devices and accessories therefore supplied for hire or compensation, and vessels, receptacles and utensils used as packages or containers in the sale and distribution of any natural or processed product, compound, mixture or substance, or any combination thereof, and parts and accessories for such vessels, receptacles and utensils. G. This registration is effective until January 1, 2011 and will continue in effect for additional terms of ten years each if form DSCB:54-1314/1515 (Decennial Report-Insignia/Mark Used with Articles or Supplies) is timely filed in the year 2010 and each year thereafter divisible by ten. H. This form and all accompanying documents shall be mailed to the address stated above. American LegalNet, Inc. www.FormsWorkFlow.com