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1. Name of conveying party(ies):
______________________________________
Name of Party Assigning Rights
[
] Individual(s)
[
] Association
[
] General Partnership [
] Limited Partnership
[
] Corporation-State [
] Other _____________________
Additional
name(s) of conveying party(ies) attached?
[
] Yes [ ]
No
3.
Nature of Conveyance:
[ ] Assignment
[ ]
Merger [
] Security Agreement
[ ] Change of
Name [
] Other ________________________
Execution
Date: ____________________________________
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2.
Name and address of receiving party(ies):
Name:
________________________________________
Internal Address:
_______________________________
Street
Address: _______________________________
City _____________________ State _____ ZIP _____
[
] Individual(s) Citizenship
_________________________ [
] Association ___________________________________ [
] General Partnership ____________________________ [
] Limited Partnership _____________________________ [
] Corporation-State ______________________________ [
] Other ________________________________________ If
assignee is not domiciled in the United States, a domestic
representative designation is attached.
[
] Yes [
] No
(Designation must be a separate document from
Assignment.) Additional
name(s) & address(es) attached?
[ ] Yes [
] No |
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4A.
Application No.(s)
_________________________________________________
Application No.(s) - if Applicable
Additional
numbers attached? [ ]
Yes [ ] No
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4B.
Registration No.(s)
______________________________________
Registration No.(s) - if Applicable
Additional
numbers attached? [ ]
Yes [ ] No
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5.
Name and address of party to whom correspondence concerning document should be mailed:
Name:
___________________________________
Responsible Attorney
________________________________
Address
________________________________
City:
________________ State: _____ ZIP: _____
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6.
Total number of applications and registrations
involved: [ ]
7.
Total fee (37 CFR 3.41):.....$
___________
8.
Method of Payment
[ ]
Enclosed
[ ]
The Commissioner is authorized to charge payment of any
additional recording fees or credit any overpayment to
deposit account No. __________________________. A
duplicate copy of this page is enclosed.
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9.
Statement and signature.
To
the best of my knowledge and belief, the foregoing
information is true and correct and any attached copy is a
true copy of the original document.
Signature
____________________
Name
of Person Signing
Date
Total
number of pages including cover sheet, attachments and
document: [ ]
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