Form PTO-1611 Application for Recordal of Insignia or Renewal/Reactiva

Application for Recordal of Insignia
or

Renewal/Reactivation of Recordal
Under the Fastener Quality Act
15 U.S.C. § 5401 et seq.
15 C.F.R. § 280.300 et seq.

USPTO Form 1611(Rev. 10/2007)
U.S. Patent and Trademark Office
U.S. DEPARTMENT OF COMMERCE
OMB Control No. 0651-0028 (Exp. 06/30/2009)
Under the Paperwork Reduction Act of 1995,
no persons are required to respond to a
collection of information unless it displays a
valid OMB control number.

APPLICATION FOR RECORDAL OF INSIGNIA UNDER THE FASTENER QUALITY ACT

or Renewal/Reactivation of Recordal 15 U.S.C § 5401 et. seq. (15 C.F.R. §280.300 et. seq.)
page 3 of 3

Instructions
To request recordal:
1. Complete sections 1 through 4 of USPTO Form 1611
2. Sign and date the form
3. Attach a copy of your trademark registration certificate or application drawing page, as
appropriate
4. Attach a check or money order in U.S. Currency or a completed credit card authorization
form, or include a USPTO Deposit Account number for required fees*
5. Submit form either by mail, by fax, or by email
To request renewal:
1. Complete sections 1, 2, 3 and 5 of USPTO Form 1611
2. Sign and date the form
3. Attach a copy of the certificate of recordal
4. Attach a check or money order in U.S. Currency or a completed credit card authorization
form, or include a USPTO Deposit Account number for required fees*
5. Submit form either by mail, by fax or by email
To request reactivation:
1. Complete sections 1, 2, 3 and 6 of USPTO Form 1611
2. Sign and date the form
3. Attach a copy of the certificate of recordal
4. Attach a check or money order in U.S. Currency or a completed credit card authorization
form, or include a USPTO Deposit Account number for required fees*
5. Submit form either by mail, by fax, or by email
To submit form via mail, please send form, required attachments and method of payment to
the address below.
Director, USPTO
ATTN: FQA
600 Dulany Street
MDE 10-A71
Alexandria VA 22314-5793
To submit form via fax, please transmit form, required attachments and method of payment
to 571.273.8950
To submit form via email, please attach completed form, scanned versions of required
attachments, and method of payment to an email, indicate “ATTN: FQA” in the subject field,
and transmit to tmfqa@uspto.gov.
Credit card authorization form and instructions are available at www.uspto.gov/web/
forms/2038.pdf.
The fee for recordal, renewal and reactivation is currently $20 per application. Fees are
subject to change. If renewal is requested within six months following the expiration of the
certificate of recordal, a $20 surcharge is required. For more information see http://www.
uspto.gov/web/offices/ac/qs/ope/fees.htm for current USPTO fee schedule.

APPLICATION FOR
RECORDAL
OF INSIGNIA
UNDER THE
FASTENER
ACT QUALITY ACT
APPLICATION
FOR
RECORDAL
OF INSIGNIA
UNDER
THEQUALITY
FASTENER

or
Recordal
15 U.S.C
§ 5401
et. seq.
C.F.R.
et. seq.) et. seq.)
or Renewal/Reactivation
Renewal/Reactivationofof
Recordal
15 U.S.C
§ 5401
et.(15
seq.
(15§280.300
C.F.R. §280.300
page
page 11of
of33

1

Applicant’sName
Name
Applicant’s
If the applicant is an individual, please indicate the applicant’s legal name. If
the applicant is a corporation, the applicant’s name is the name under which
the applicant is legally incorporated. If the applicant is a partnership, the
applicant’s name is the name under which the applicant is legally organized.
For individuals,First
please enter the
lastMiddle
name, or
firstinitial
name, and middle
Last
name or initial

2

Applicant’s Contact Information
Enter the applicant’s entire business address, including ZIP or other postal codes. The
applicant may designate a correspondence address in the event correspondence should be
sent elsewhere.
Note: The recordal applicant or the holder of a Certificate of Recordal must notify the USPTO
in writing of any change of address within six (6) months after the change.
Business Business
STREET
STREETADDRESS
ADDRESS

SUITE
SUITE

CITY
ZIP CODE
CITY
STATE STATE ZIP CODE

Correspondence
Correspondence
(if different)
(if different)

TELEPHONE
TELEPHONE

EMAIL
EMAIL

STREET ADDRESS
STREET
ADDRESS

SUITE
SUITE

CITY STATE STATE ZIP CODE
ZIP CODE
CITY
TELEPHONE
TELEPHONE
FACSIMILE

3

EMAIL
EMAIL

Applicant’s Legal Entity & Citizenship
If this information is for:

an individual. Please enter country of citizenship.

a partnership. Please enter the state where legally organized, or country,

if appropriate, AND the names and country of citizenship of all general partners.

a corporation. Please enter the state, or country, if appropriate, of incorporation.

other. Please enter the specific nature of the entity and the state or country, if

appropriate, of citizenship.

APPLICATION FOR RECORDAL OF INSIGNIA UNDER THE FASTENER QUALITY ACT

or Renewal/Reactivation of Recordal 15 U.S.C § 5401 et. seq. (15 C.F.R. §280.300 et. seq.)
page 2 of 3

4

Request for Recordal
The applicant requests the USPTO to assign a unique alphanumeric designation for
recordal on the Fastener Insignia Register.
The applicant requests recordal of the mark on the Fastener Insignia Register using the
U.S. Registration Number or U.S. Serial Number entered below.
The applicant is the owner of the referenced trademark registration or application, which
is not cancelled, abandoned, or expired. A copy of the registration certificate or the
drawing in the trademark application is attached.
or
U.S. REGISTRATION NUMBER

5

U.S. APPLICATION SERIAL NUMBER

Request for Renewal
A Certificate of Recordal remains “active” for a period of five (5) years from the date of issuance. To
maintain active status, a complete renewal application must be received in the USPTO within the
six (6) months period prior to the expiration of that five year term.

The applicant requests renewel of the applicant’s Certificate of Recordal based on
either:
or
TRADEMARK APPLICATION SERIAL NUMBER
or
TRADEMARK REGISTRATION NUMBER
or
ALPHANUMERIC DESIGNATION
A copy of the Certificate of Recordal is attached.

This collection of information is required under 15 U.S.C. § 5401 et seq. and 15 C.F.R. § 280.300 et seq. The public
submits the information in connection with requests to record or renew insignia under the Fastener Quality Act of 1999,
and the USPTO uses the information to process these requests.
The time required to complete the form, including gathering information, preparing the form, and submitting the completed
requests to the USPTO is estimated to be ten minutes. Time will vary depending on the particular circumstances. Any
comments on the amount of time you require to complete this form and/or suggestions for reducing this burden should be
sent to the Chief Information Officer, USPTO, P.O. Box 1450, Alexandria VA 22313-1450.
Do not send fees or completed forms to this address. Send them to: Director, USPTO, ATTN: FQA, 600 Dulany Street,
MDE-10A71, Alexandria VA 22314-5793.

Applicant

APPLICATION FOR RECORDAL OF INSIGNIA UNDER THE FASTENER QUALITY ACT

or Renewal/Reactivation of Recordal 15 U.S.C § 5401 et. seq. (15 C.F.R. § 280.300 et. seq.)
page 2 of 3

6

Request for Reactivation
When a previously recorded alphanumeric designation is assigned to another entity the
recordal becomes “inactive” as of the date of the assignment. The new owner of the
alphanumeric designation must “reactivate” the designation by filing a new application
and requesting reactivation. The assignment documents must also be submitted with
the application. Note: Only one recorded alphanumeric designation may be reactivated
per application. Where a Certificate of Recordal is based on a trademark application or
registration and the underlying application or registration has been assigned, the recordal
shall be designated “inactive,” and CANNOT be reactivated. See 15 C.F.R. §280.323(b).
The new trademark owner must apply for a new recordal.
The applicant request reactivation of the recorded Alphanumeric Designation listed
below. A copy of the assignment documents are attached.
ALPHANUMERIC DESIGNATION

7

Verification
The applicant identified below is a manufacturer as defined in 15 U.S.C. §5401. The applicant
will comply with the applicable provisions of the Fastener Quality Act (15 U.S.C. §§5401 et
seq.). The undersigned has knowledge of the facts relevant to the application and possesses
the authority to act on behalf of the applicant. The undersigned declares, under penalty of
perjury under the laws of the United States of America, that the information and statements
included in this application are true and correct.
The prescribed fee must accompany this application. You have three options to submit this
form.
1. You may sign this form electronically by typing the applicant’s name in between frontslashes. (example: /John Smith/) and click the submit button to email your information to
tmfqa@uspto.gov, if you are paying the prescribed fee with a line for deposit account with the
USPTO. Please email us any attachments.
2. You may print, manually sign, and fax this form to 571.273.8950 or print, manually sign,
scan, and email all documents to tmfqa@uspto.gov, if you are paying the prescribed fee
from a deposit account with the USPTO. You may also fax or email a completed credit card
authorization form located at www.uspto.gov/web/forms/2038.pdf.
3. You must print, manually sign, and mail this form if you are paying by check. Please mail
the check with this form. Keep a copy for your records.
APPLICANT’S SIGNATURE
PRINT OR TYPE NAME AND POSITION OR TITLE OF SIGNER
DATE
DEPOSIT ACCOUNT INFORMATION (IF APPLICABLE)

Applicant