Legal Deregistration Form

LEGAL DEREGISTRATION FORM

This Legal Deregistration Form (the "Form") is made and entered into as of Effective Date: by and between Registrant Name: (the "Registrant") and Registrar Name: (the "Registrar"). The Registrant and the Registrar are each a "Party" and together the "Parties."

RECITALS

WHEREAS, the Registrant is the recorded holder of the registration identified as Registration Number: registered with the Registrar in connection with Registration Type: ;

WHEREAS, the Registrant has requested that the Registrar remove, terminate or otherwise deregister the registration described above and to reflect the deregistration in the Registrar's records effective as of the Effective Deregistration Date set forth below; and

WHEREAS, the Parties desire to document the Registrant's request, the Registrar's acceptance and the terms, representations and certifications necessary to effectuate deregistration.

NOW, THEREFORE

In consideration of the mutual covenants and agreements set forth below, the Parties agree as follows:

1. REQUEST FOR DEREGISTRATION

1.1 Request. The Registrant hereby requests that the Registrar deregister and remove the registration identified above. Effective Deregistration Date: .

1.2 Scope of Deregistration. The deregistration shall apply to the registration identified by Registration Number and shall include removal of all active rights and notices associated with that registration from the Registrar's public and internal records, subject to the terms of this Form and any restrictions or encumbrances expressly identified herein.

2. CERTIFICATIONS BY REGISTRANT

2.1 Authority. The Registrant represents and warrants that the person executing this Form on behalf of the Registrant is duly authorized to request deregistration and to bind the Registrant to the terms of this Form. Authorized Representative Name: , Title: .

2.2 No Outstanding Encumbrances. The Registrant certifies that, to the Registrant's knowledge, no liens, mortgages, judgments, or other encumbrances exist that would prevent deregistration, except as described in Encumbrance Disclosure below:

3. REPRESENTATIONS, WARRANTIES AND COVENANTS

3.1 Compliance with Law. Each Party represents and warrants that it has complied and will comply with all applicable statutes, regulations and administrative procedures required to effectuate the deregistration requested herein.

3.2 Records and Information. The Registrant shall promptly provide all documents, records and instruments reasonably requested by the Registrar to process the deregistration. Failure to provide complete and accurate information may delay or void the deregistration.

4. RELEASE AND INDEMNIFICATION

4.1 Release. Upon acceptance and completion of the deregistration by the Registrar, the Registrant releases the Registrar from any liability arising solely from the Registrar's execution of the deregistration in accordance with the Registrant's request and this Form, except for actions resulting from the Registrar's gross negligence or willful misconduct.

4.2 Indemnification. The Registrant shall indemnify, defend and hold harmless the Registrar and its officers, agents and employees from and against any and all claims, losses, liabilities, damages, costs and expenses (including reasonable attorneys' fees) arising out of or relating to the Registrant's breach of any representation, warranty or covenant in this Form or any misstatement of material fact contained herein.

5. FEES, TAXES AND REFUNDS

5.1 Fees. The Registrant acknowledges responsibility for any fees or charges required by the Registrar to process the deregistration. Fee Amount (if applicable): .

5.2 Taxes and Refunds. The Parties agree that any applicable taxes remain the responsibility of the Registrant. Any refund or credit due as a consequence of deregistration shall be determined in accordance with Registrar policy and shall not constitute an admission of liability.

6. NOTICES

All notices, requests, consents and other communications required or permitted under this Form shall be in writing and shall be delivered to the addresses set forth below. Notices shall be deemed delivered on the date of personal delivery, three (3) days after deposit in the United States mail, postage prepaid, or on the date of confirmed electronic transmission when sent by email.

7. CONFIDENTIALITY

The Parties acknowledge that information provided in connection with this Form may be confidential. Except as required by law or as necessary to effectuate the deregistration, neither Party shall disclose confidential information of the other Party without prior written consent.

8. GOVERNING LAW; DISPUTE RESOLUTION

This Form shall be governed by and construed in accordance with the laws of the State/Province specified below, without regard to conflict of law principles. Governing Law State/Province: .

Any dispute arising out of or relating to this Form shall be resolved by the courts of the governing law jurisdiction, and the Parties consent to the exclusive jurisdiction and venue of such courts.

9. ENTIRE AGREEMENT; SEVERABILITY; AMENDMENT; WAIVER; COUNTERPARTS

9.1 Entire Agreement. This Form constitutes the entire agreement between the Parties with respect to its subject matter and supersedes all prior understandings, agreements and representations, whether written or oral.

9.2 Severability. If any provision of this Form is held to be invalid, illegal or unenforceable in any respect, the validity, legality and enforceability of the remaining provisions shall not be affected or impaired thereby.

9.3 Amendment and Waiver. No amendment, modification or waiver of any provision of this Form shall be effective unless in writing and signed by both Parties. The failure of a Party to enforce any provision shall not constitute a waiver of that provision.

9.4 Counterparts. This Form may be executed in counterparts, each of which when executed shall be deemed an original, and all counterparts together shall constitute one and the same instrument. Electronic or facsimile signatures shall have the same force and effect as original signatures.

10. ACKNOWLEDGMENT AND CERTIFICATION

The Registrant certifies under penalty of perjury that the information provided in this Form is true, complete and correct to the best of the Registrant's knowledge, and that the Registrant is authorized to request the deregistration described herein.

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