112 [Subsidiary] CAP. 506 Trade Marks [Rev. 2009 to the trade mark described above, be changed to the following: ………………………………………………………………………………… ……………………………………………………………………………....... Description of circumstances in which name or description has changed: ………………………………………………………………………………… ……………………………………………………………………………....... Date: …………………………………………………………………............. Signature: ……………………………………………………………............. To: The Registrar of Trade Marks. L.N. 146/2003. FORM TM 21 Application To Surrender Trade Mark For All Goods And Services (rule 84A (1) (a)) In the matter of Trade Mark No. ………………………………………… Class: ……………………………………………........................... Name of registered proprietor: ………………………………........ Trade or business address: ……………………………………...... Description of trade mark: ……………………………………….. I, the proprietor of the trade mark described above, apply to surrender the trade mark in respect of all the goods or services in respect of which it is registered. Names and addresses of persons with a registered interest in the trade mark: ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… Attached to this application is a certification by the proprietor that each person with a registered interest listed above either – (i) has been given notice of the proposed surrender at least ninety days before the application is made; or (ii) is not affected by the surrender or has consented to it. Date: …………………………………………………………….................... Signature: ……………………………………………………........................