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Form Tm 3 - Application For Certificate Of Name Change Of An Applicant Or Registrant Page 2

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:__________________________________

Form Tm 3 - Application For Certificate Of Name Change Of An Applicant Or Registrant Page 2