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Application For Certificate Of Renewal Of A Registered Mark - Connecticut Secretary Of The State

OFFICE OF THE SECRETARY OF THE STATE

MAILING ADDRESS:

DELIVERY ADDRESS:

Commercial Recording Division

Connecticut Secretary of the State

P.O. Box 150470

30 Trinity Street

Hartford, CT 06115-0470

Hartford, CT 06106

860-509-6003

APPLICATION FOR CERTIFICATE OF RENEWAL OF A REGISTERED MARK

(Can be filed only within 6 months prior to the expiration of a registration)

Filing Fee: $100.00

Make Checks Payable To “Secretary of the State”

1. Name of Record Owner:

2. State of Formation of the Owner if other than a natural person:

3. New Address of Owner (if applicable):

____________________________________

4. Connecticut Registration Number: ____________________________

The owner of the mark, which is the subject of this application, asserts that the mark has been and is still in use

in Connecticut. The owner hereby applies for renewal of the registration bearing the number stated in Number

4 above.

EXECUTION:

I hereby declare under the penalties of false statement that the statements made in

the foregoing application are true.

5. ___________

6. ________________________________

7. ______________________________

Date

Name of Signatory

Title of Signatory if applicable

8. _________________________________________________________________

Signature

The applicant must submit three specimens or photographs of the mark as actually used in this state.

Revised 4/8/10

Application For Certificate Of Renewal Of A Registered Mark - Connecticut Secretary Of The State