PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Trade Mark/Service Mark (54 Pa.C.S.) Renewal of Registration of Mark (§ 1114) Assignment of Registration of Mark (§ 1115) Document will be returned to the name and address you enter to the left. Name Address City State Zip Code Fee: $50 - Renewal $50 - Assignment In compliance with the requirements of the applicable provisions (relating to duration and renewal or relating to assignment), the undersigned, having heretofore duly registered a trade mark or service mark in this Commonwealth and desiring to renew/assign such registration, hereby states that: 1. Check one pertaining to registration: Renewal: The name and description of the mark is (a specimen of the mark the registration of which is to be renewed showing actual use of the mark on or in conjunction with the goods or services accompanies this application as Exhibit A and is incorporated herein by reference): Assignment: The name and description of the mark is (a facsimile of the mark the registration of which is to be assigned accompanies this assignment as Exhibit A and is incorporated herein by reference): 2. The residence, location or place of business of the applicant/assignor is: Number and street City State Zip County American LegalNet, Inc. www.FormsWorkFlow.com DSCB:54-1114/1115 – 2 3. Check one pertaining to registration: Renewal: The name of the applicant is (see instruction D): Assignment: The name of the assignor and present owner of record of the mark is (if a corporation, also give jurisdiction of incorporation): 4. The general class in which the existing registration/registration to be assigned applies is: 5. (a) The date when the mark was first registered is: (b) The date of last renewal of the registration is: RENEWAL: Complete Paragraphs 6, 7 & 8 6. (Strike out if inapplicable): The present applicant is entitled to make the present application by virtue of an assignment to the applicant recorded with the Department of State on showing an assignment from: Date Name of Assignor 7. The date, if any, an application to register the mark, or portions or a composite thereof, was filed by the applicant or a predecessor in interest in the United States Patent and Trademark Office. Also provide filing date and serial number of each application, the status thereof and, if any application was finally refused registration, or has otherwise not resulted in a registration, the reasons, therefore. (Please attach 8½ x 11 sheet(s) if more space is needed). 8. The mark to be renewed is still in use in this Commonwealth American LegalNet, Inc. www.FormsWorkFlow.com DSCB: 54-1114/1115-3 ASSIGNMENT: Complete Paragraphs 9, 10, 11 & 12 9. The mark is being assigned with the goodwill of the business connected with its use or with that part of the goodwill of the business connected with the use of and symbolized by the mark. 10. The mark is hereby assigned to and the name of the assignee of the mark is (if a corporation, also give jurisdiction of incorporation): 11. The residence, location or place of business of the assignee is: Number and street City State Zip County 12. (Strike out if inapplicable): The present assignor is entitled to make the present assignment by virtue of a previous assignment to the present assignor recorded with the Department of State on . Date Name of Previous Assignor IN TESTIMONY WHEREOF, the undersigned person has caused this Application for Renewal of Registration of Mark/Assignment of Registration of Mark to be executed this day of , . Name of Applicant/Assignor 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 General 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 Renewal of Registration of Mark is $50 and Assignment of Registration of Mark is $50 made payable to the Department of State. B. This form and all accompanying documents shall be mailed to the above stated address. Instructions for Renewal Only: D. If a corporation, set forth the name in Paragraph 1 and also give jurisdiction of incorporation. If a partnership, set forth the name in Paragraph 1 and also give the jurisdiction in which the partnership is organized and the names of the general partners. E. The name of a commercial registered office provider may not be used in Paragraph 2 in lieu of an address. F. If the chain of title to the registration includes more than one assignment, Paragraph 6 should be modified accordingly. Only assignments during the immediately preceding term shall be set forth. G. This renewal is effective for a term of 5 (five) years from the expiration date. Application to renew for a similar term must be made on this form within 6 (six) months prior to the expiration date. Instructions for Assignment Only: H. The name of a commercial registered office provider may not be used in Paragraph 2 and 11 in lieu of an address. I. If the chain of title to the registration includes more than one assignment, Paragraph 12 should be modified accordingly. Only assignments during the current term shall be set forth. J. If the instrument evidencing the assignment and signed by the assignor is in a different format than this form, the assignee may execute and attach this form as a cover sheet to a copy of the definitive assignment instrument. American LegalNet, Inc. www.FormsWorkFlow.com