Assignment of application for registration. _________[name of assignor], of _________[street, city, and state], has adopted and is using a mark for which —he has filed application in the United States Patent and Trademark Office for registration, Serial No. _________; and _________[name of assignee], of _________[street, city, and state], is desirous of acquiring this mark; [and, Assignor has filed a verified statement of use under 15 USCA §1051(d) in regard to this mark; ] Now, therefore, for good and valuable consideration, receipt of which is here acknowledged, _________[name of assignor] does here assign unto _________[name of assignee] all rights, title and interest in and to this mark, together with the goodwill of the business symbolized by the mark, and the above-identified application for registration of the mark. The commissioner of patents and trademarks is requested to issue the certificate of registration to the assignee. _________[Signature of assignor; if assignor is a corporation or other juristic organization, give the official title of the person who signs for assignor.] State of _________ ss County of _________
On this _________ day of _________, _________[date], before me appeared _________, the person who signed this instrument, who acknowledged that —he signed it as a free act on h— own behalf (or on behalf of the identified corporation or other juristic entity with authority to do so). _________, Notary Public