APPLICATION FOR REGISTRATION OF TRADEMARK OR SERVICE MARK (SS-4264) Tre Hargett, Secretary of State State of Tennessee 312 Rosa L. Parks Ave., 6th Fl. Nashville, TN 37243 615-741-0531 Business Services Division For Office Use Only Filing Fee: $20.00 per class In compliance with the requirements of T.C.A. § 47-25-503, the undersigned, having adopted and used a trademark or service mark in this State for the purposes provided in T.C.A. § 47-25-501 et seq., hereby certifies under oath and penalty of perjury the following statements: 1. Applicant Name: 2. Applicant Address: City: Phone #: 3. If the applicant is a corporation, the state of incorporation is: 4. If the applicant is a partnership, the state where the partnership is organized is and the names of the general partners are: 5. This mark is used on or in connection with what goods or services? State: Zip Code: 6. In what mode or manner is the mark used in connection with these goods or services? 7. The class in which such goods or services fall: Class Number: Name of Class: 8. The date when the mark was first used (must be a date prior to signature date of application; must be month/day/year): a) Anywhere: Month / Day / Year b) In Tennessee: Month / Day / Year 9. Name and description of the mark in words: 10. One specimen showing the mark as actually used accompanies this application. 11. The applicant is the owner of the mark, and the mark is in use. To the knowledge of the person verifying this application, no other person has registered, either federally or in Tennessee, or has the right to use the mark in an identical form or in such near resemblance as to be likely, when applied to the goods or services of such other person, to cause confusion or mistake, or to deceive. State of County of Sworn to and subscribed before me this Notary Public My Commission Expires: day of , 20 Signature Type or Print Name & Title (Rev. 6/13) American LegalNet, Inc. www.FormsWorkFlow.com RDA 1764