Form Mark-1a - Mark Disclaimer Page 2
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1
2D.
I understand that I may not prevent another from using the disclaimed portion of this mark except as it might directly infringe
on my rights as holder of this registered mark.
Dated: _______________________
____________________________________________________
(applicant's signature)
****************************************************************************************************************
State of ______________ County of ______________________
____________________________________________________
(print/type applicant's name)
personally
appeared
and
acknowledged
the
foregoing
instrument by him/her subscribed to be his/her free act and
deed.
____________________________________________________
Notary Public
Dated: _______________________
SUBMIT COMPLETED FORMS TO: CORPORATE EXAMINING SECTION, SECRETARY OF STATE,
101 STATE HOUSE STATION, AUGUSTA, ME 04333-0101
FORM NO. MARK-1A
Rev. 4/16/2001
TEL. (207) 624-7740
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