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Form Tm 3 - Application For Certificate Of Name Change Of An Applicant Or Registrant

APPLICATION FOR CERTIFICATE OF NAME CHANGE OF AN APPLICANT OR

REGISTRANT

A certificate of name change is filed when the name of the owner of the mark has changed and

there is no change in the entity type (i.e. corporation, limited liability company, sole proprietor, etc.).

(See Form TM3)

Applicant (owner name and address): The applicant is the individual or entity that

Item 1

owns the mark.

If the applicant is a partnership, both individuals must be listed

as the owner and both must sign the application before a notary public.

Contact person name and address: Name and address of person we may contact

Item 2

with any questions we may have. (Please furnish an email address, if available).

Item 3

Prior name of applicant (prior owner name and address): The prior applicant is

the previous name of the individual or entity that owns the mark.

Item 4

Applicant is a: Indicate the entity type and state of jurisdiction or formation as it is

on the current certificate of registration.

Item 5

Name change effective date and kind of mark: Indicate the name change effective

date. Indicate the registration type of the mark as a trademark or service mark as

it is on the current certificate of registration.

Item 6

Identify each trademark or service mark for which the name change is applicable

(or attach an exhibit): Indicate the mark(s) on this line. If the mark is comprised

of words only, type or write the words here. If the mark also includes a design,

symbol or image, attach an exhibit of the mark to the application. An exhibit is a

blank piece of paper with an appearance of the mark only without extraneous

markings. A non-refundable filing fee of $30.00 made payable to the Treasurer

of Virginia is required for each mark affected by the name change.

Item 7

Describe the product or service(s) the mark represents (identifies): Describe the

product (trademark) or service(s) provided (service mark) which the mark(s)

identifies as it is on the current certificate of registration.

Item 8

Signature of applicant & notary public – The application must be signed before a

notary public.

Additional assistance can be obtained by calling (804) 371-9051 or at

Mailing address: Division of Securities & Retail Franchising, PO Box 1197, Richmond, VA 23218

Form Tm 3 - Application For Certificate Of Name Change Of An Applicant Or Registrant