Form PTO-158T Application for Recognition to Practice Before the Unite

OMB No. 0000-0000 Approval Expires 09/30/2014

FORM PTO-158T
(Rev. February 21, 2013)

United States Patent and Trademark Office

APPLICATION FOR RECOGNITION TO PRACTICE BEFORE
THE UNITED STATES PATENT AND TRADEMARK OFFICE UNDER
37 CFR 11.14(c) BY A FOREIGN RESIDENT

Under the Paperwork Reduction Act of 1995, no person is required to respond to a collection of information unless it
displays a valid OMB control number. This collection of information is required by 37 CFR § 11.14. This information
is used by the public to seek recognition to practice before the United States Patent and Trademark Office (USPTO)
and by the USPTO to determine the eligibility of the applicant to practice before the USPTO in trademark matters.
The information on this form will be treated confidentially to the extent allowed under the Privacy Act and the
Freedom of Information Act (FOIA). Response to this information collection is voluntary; however, if you do not
provide the requested information, the USPTO may not recognize you to practice before the USPTO in trademark
matters. This form is estimated to take 30 minutes to complete, including gathering, preparing, and submitting the
information on the application to the USPTO. 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, United States
Patent and Trademark Office, Washington, D.C. 20231. DO NOT SEND FEES OR COMPLETED FORMS TO
THIS ADDRESS.

SEND TO: Mail Stop OED, U.S. Patent and Trademark Office, P.O. Box 1450, Alexandria, VA 22313-1450

THIS SPACE FOR PATENT AND
TRADEMARK OFFICE USE ONLY

NAME (first name, middle name or initial, last name)
CORRESPONDENCE / BUSINESS NAME (employer, corporation, law firm, etc.)
CORRESPONDENCE / BUSINESS ADDRESS (street, building, suite, etc.)
PRIMARY E-MAIL

SECONDARY E-MAIL

CITY

STATE

ZIP CODE

BUSINESS PHONE

CITY

STATE

ZIP CODE

HOME PHONE

CITIZENSHIP (country)

DATE OF BIRTH (month, day, year)

HOME ADDRESS

PLACE OF BIRTH (city, state, country)

Please notify OED promptly of any changes in the above information in order to prevent problems with your application
processing.

1.

Enclosed is the required non-refundable application fee of $40.00 set forth in 37 CFR § 1.21(a)(1)(i).
-OREnclosed is the $1,600.00 fee set forth in 37 CFR § 1.21(a)(10).

2.

YES

NO

Have you previously applied for recognition to practice before the United States Patent
and Trademark Office in trademark matters, or have you ever received from the Office of
Enrollment and Discipline an evaluation of your qualifications?

If “YES”, provide the date and name on the application, if different from above: ___________________________

3.

I am in good standing before the Trademark Office of ________________________________.
A certificate of good standing from that Trademark Office

4.

is attached

/

was previously submitted.

I am an attorney in a foreign country. The country is ___________________________________.
Enclosed is proof that I am a foreign attorney.

FORM PTO-158T

Rev. February 21, 2013

Page 2

BACKGROUND INFORMATION: Candor and truthfulness are significant elements of fitness relevant to
practice before the United States Patent and Trademark Office. You should, therefore, provide the Office of
Enrollment and Discipline with all available information, however unfavorable, even if its relevance is in doubt,
with regard to the questions asked below. For each question answered "YES," provide a detailed statement
setting forth all relevant facts and dates along with verified copies of relevant documents. Your responses
must be updated as necessary, prior to your recognition. Any documents, evidence or proofs previously
filed in a prior application need not be resubmitted unless your response to a question must be changed.
Failure to disclose the requested information may result in denial of recognition or in disciplinary
proceedings under 37 CFR § 10.22, should you become recognized.
5.

Have any charges ever been preferred against you in connection with your practice before
any Federal or State court, or municipal bureau, commission, office or agency of any kind
or character?

YES

NO

6.

Have you ever been arrested, charged, or held by Federal, State or other law enforcement
authorities for any violation of any Federal or State law, or any country or municipal law,
regulation or ordinance? (Do not include any misdemeanor before your 16th birthday or
traffic violations for which the fine was $100 or less.)

YES

NO

7.

Have you ever been disciplined, reprimanded, suspended, expelled or asked to resign or
withdraw from any educational institution, or have you resigned or withdrawn from any such
institution in time to avoid a request to resign, discipline, reprimand, suspension, or
expulsion for conduct involving dishonesty, fraud, misrepresentation, or deceit?

YES

NO

8.

Have you ever been disciplined, reprimanded, or suspended in any job for conduct involving
dishonesty, fraud, misrepresentation, deceit, or for any violation of Federal or State laws or
regulations?

YES

NO

9.

Have you ever been fired or discharged from any job, or have been asked to resign or quit
for conduct involving dishonesty, fraud, misrepresentation, deceit, or for any violation of
Federal or State laws or regulations?

YES

NO

10. Have you ever resigned or quit a job when you were under investigation or inquiry for

YES

NO

11. Have you ever been discharged from military service under conditions "other than

YES

NO

12. Are you delinquent on any State or Federal debt or debt to a foreign state, province or

YES

NO

conduct which could have been considered as involving dishonesty, fraud,
misrepresentation, deceit, or for any violation of Federal or State laws or regulations, or after
receiving notice or being advised of possible investigation, inquiry, or disciplinary action for
such conduct?

honorable," or by reason of the sentence of a Court Martial or being dropped from the rolls?
country? (Include delinquencies arising from Federal or State or foreign taxes, loans,
overpayment of benefits, and other debts to the U.S. Government or a foreign government
and defaults on Federally or foreign state, province or country guaranteed or insured loans
such as student and home mortgage loans.)

Upon the basis of the foregoing information and any attached documents, I hereby apply for recognition to
practice in trademark matters before the United States Patent and Trademark Office. I certify that each and
every statement or representation in this application is true and correct.
(A willfully false statement or certification is a criminal offense and is punishable by law (18 U.S.C. § 1001)).

Signature of Applicant

Date

Mail completed application to:
Mail Stop OED, United States Patent and Trademark Office, P.O. Box 1450, Alexandria, VA 22313-1450

PRIVACY ACT ADVISORY STATEMENT
The Privacy Act of 1974 (P.L. 93-579) requires that you be given certain information in connection with the request for
information solicited on attached form PTO-158T. Accordingly, pursuant to the requirements of the Act, please be advised
that (i) the authority for the collection of this data is 35 U.S.C. §§ 1 and 2(b)(2)(D); (ii) furnishing of the information
solicited is voluntary; and (iii) the principal purpose for which the data will be used is to maintain current information
relating to your eligibility and fitness for recognition to practice before the United States Patent and Trademark Office in
trademark matters. If you do not furnish the requested information, you will not be recognized to practice before the Patent
and Trademark Office.
The information provided by you in this form will be subject to the following routine uses:
1.

Information from PTO-158T may be published by the United States Patent and Trademark Office in
the Official Gazette to solicit information tending to affect your eligibility on moral, ethical, or other grounds for
recognition pursuant to 37 CFR § 11.14. Information from PTO-275 may be published to provide the public with a
roster of recognized practitioners pursuant to 37 CFR § 11.14.

2.

Disclosure may be made to any Government agency, professional organization, or individual, if necessary, to obtain
information relevant to an investigation concerning the suitability of an applicant for registration to practice before
the Patent and Trademark Office.

3.

Disclosure may be made to a Federal, state, local, foreign, tribal, or other public authority of the fact that this
system of records contains information relevant to the retention of an employee, retention of a security clearance,
the letting of a contract, or the issuance or retention of a license, grant, or other benefit. The other agency or
licensing organization may then make a request supported by the written consent of the individual for the entire
record, if it so chooses. No disclosure will be made unless the information has been determined to be sufficiently
reliable to support a referral to another office within the agency, or to another Federal agency for criminal,
administrative, personnel, or regulatory action.

4.

Disclosure may be made to a court or adjudicative body in a proceeding when: (a) the agency or any component
thereof; (b) any employee of the agency in his or her capacity; (c) any employee of the agency in his or her official
capacity where the agency has agreed to represent the employee; or (d) the United States Government is a party to
litigation or has an interest in such litigation and by careful review, the agency determines that the records are both
relevant and necessary to the litigation and the use of such records is therefore deemed by the agency to be for a
purpose that is compatible with the purpose for which the agency collected the records.

5.

Disclosure may be made to a member of Congress or to a congressional staff member in response to an inquiry of
the Congressional office made at the written request of the constitutent about whom the record is maintained.

6.

Information may be disclosed to the Office of Management and Budget (OMB) in connection with a review of
private relief legislation (as set forth in OMB Circular No. A-19) at any stage of the legislative coordination and
clearance process described in the Circular.

7.

The information may be disclosed to the agency contractors, grantees, experts, consultants, or volunteers who have
been engaged by the agency to assist in the performance of a service related to this system of records and who have
need to have access to the records in order to perform the activity. Recipients of information shall be required to
comply with the requirements of the Privacy Act of 1974, as amended, pursuant to 5 U.S.C. § 552a(m).

8.

The information may be disclosed to the Office of Personnel Management (OPM) for personnel research purposes
as a data source for management information, for the production of summary descriptive statistics and analytical
studies in support of the function for which the records are collected and maintained, or for related manpower
studies.

9.

Records from this system of records may be disclosed to the National Archives and Records Administration or to
the General Services Administration for records management inspections conducted under 44 U.S.C. §§ 2904 and
2906.

10. When a record on its face, or in conjunction with other records, indicates a violation or potential violation of law,
whether civil, or criminal, or regulatory in nature, and whether arising by general statute or particular program
statute, or by regulation, rule, or order, issued pursuant thereto, disclosure may be made to the appropriate agency,
whether Federal, foreign, state, local or tribal, or other public authority responsible for enforcing, investigating, or
prosecuting violations, or charged with enforcing or implementing the statute or rule, regulation, or order issued
pursuant thereto, if the information disclosed is relevant to any enforcement, regulatory, investigative, or prosecutive
responsibility of the receiving entity.