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SECRETARY OF STATE

ASSIGNMENT OF REGISTRATION OF A TRADEMARK OR SERVICE MARK,
CERTIFICATION MARK, OR COLLECTIVE MARK

Fee: $_______

File Number: _______________________________  Class: _____________________________

MARK AS DESCRIBED ON CERTIFICATE: ____________________________________________

______________________________________________________________________________

Name of Present Registrant:
______________________________________________________________________________

Address of Present Registrant:

______________________________________________________________________________
Street 
______________________________________________________________________________
City                                                                       State                                Zip Code

The present registrant has filed this mark and is assigning this registration and all
rights to and interest in this mark, including any good will connected to the mark for
valid consideration which has been received.

This mark is assigned to:

Name:
______________________________________________________________________________

Address:

______________________________________________________________________________
Street 
______________________________________________________________________________
City                                                                       State                                Zip Code

State of Formation, if an entity: ____________________________________________

I certify that I am authorized to sign this certificate, and I further certify that I
understand that by signing this certificate, I am subject to the penalties of perjury
as set forth in applicable state statutes as if I had signed this certificate under
oath.

__________________________________________________________
Signature 

______________________ 
Date

__________________________________________________________
Print Name and Title

__________________________________________________________

All of the information on this form is public and required in order to process this
filing.  Failure to provide the requested information will prevent the Office from
approving or further processing this filing.