TM 3 (11/09)
COMMONWEALTH OF VIRGINIA
STATE CORPORATION COMMISSION
DIVISION OF SECURITIES AND RETAIL FRANCHISING
CERTIFICATE OF NAME CHANGE OF AN APPLICANT OR REGISTRANT
(Please type or print)
Applicant/Registrant name and address:___________________________________________________________________
____________________________________________________________________________________________________
Contact person name and address:________________________________________________________________________
_________________________________Daytime phone: __________________ Fax number:________________________
Prior name of applicant/registrant and address: _____________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Applicant is a:________________________________Applicant's state or jurisdiction of formation:___________________
(
entity type i.e. corporation, partnership, etc)
Kind of mark (check one): Trademark ___ Service Mark ___ Date name change effective:________________________
Identify each trademark or service mark for which the name change is applicable (or attach an exhibit of the exact mark(s)):
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Describe the product(s) or service(s) the mark represents (identifies):____________________________________________
___________________________________________________________________________________________________
(NOTE: The certificate must be signed in the name of the applicant, either by the applicant or by a person
authorized by the applicant. The certificate must be sworn to by the person who signed the name of the applicant.)
Signature:____________________________________________________Date:_________________________________
Signer’s Name:________________________________________________Title:_________________________________
(print or type)
State of :_____________________________________, County/City of:__________________________________, to-wit:
The foregoing certificate was subscribed and sworn to before me by:___________________________________________
on the __________________________ day of __________________________, ____.
My Commission Expires:_______________________________ Notary Public:__________________________________