Contact Info Form

A pplication

OMB 0651-0066 Approved for use through 7/31/12.

U.S. Patent and Trademark Office; U. S. DEPARTMENT OF COMMERCE

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.

Contact Info Form

This information will be used to notify applicants if they are selected to win an award.

Applicant(s): ______________________________________________________________

Contact Person (optional): ____________________________________________________

Mailing Address: ___________________________________________________________

Telephone: _______________________ Email: __________________________________

Preferred contact method: _________________________________

Disclaimers

_____ Please initial to indicate you have read and accept the following terms and conditions:

• Except for this contact info form, all contents of this Patents for Humanity application will be publicly available. I will not include any information in my application that I want to remain confidential, including trade secrets, unpublished patent application details, classified material, or other confidential business information. I hereby provide express authorization, to make the contents of my submission publicly available or otherwise not confidential.

• Material submitted in this application may be used by the U.S. Patent & Trademark Office for promotional, educational, or other purposes. I hereby waive any objections or claims to use of my submission by the USPTO.

Signature: _______________________________________ Date: ___________________

It is estimated that the Humanitarian Award Application will take 4 hours to complete. Applying for the Award is voluntary; however, if you apply you must provide the information requested. Failure to provide this information may delay or prevent processing of your application. Please send any comments on the amount of time required to complete this form and/or suggestions for reducing the time burden to the Chief Information Officer, USPTO, PO Box 1450, Alexandria, VA 22313-1450. DO NOT SEND APPLICATIONS TO THIS ADDRESS