Form USPTO Form 1611 USPTO Form 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. Section 5401 et seq.
15 C.F.R. Section 280.300 et seq.

USPTO Form 1611 (Rev. 05/2011)
U.S. Patent and Trademark Office
U.S. DEPARTMENT OF COMMERCE
OMB Control No. 0651-0028 (Exp. 02/29/2012)
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 Fastner Quality Act or
Renewal/Reactivation of Recordal
15 U.S.C. Section 1504 et seq. (15 C.F.R. Section 280.300 et seq.)
page 2 of 5

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 USPTO Deposit Account number for required fees.
5. Submit the form either by mail, by fax, or by e-mail.

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 the form either by mail, fax, or by e-mail.

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 the form either by mail, fax, or by e-mail.
To submit the 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 the form via fax, please transmit form, required attachments and method of payment
to 571.273.8950.
To submit the 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.
The 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
www.uspto.gov/web/offices/ac/qs/ope/fees.htm for current USPTO fee schedule.

Application For Recordal Of Insignia Under the Fastner Quality Act or
Renewal/Reactivation of Recordal
15 U.S.C. Section 1504 et seq. (15 C.F.R. Section 280.300 et seq.)
page 3 of 5

1 Applicant's Name
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,
please enter
the last name,
first name, and
middle 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 Address
Street Address

Suite

City

State

Telephone

Email

Zip Code

Correspondence Address (if different)
Correspondence Name
Street Address

Suite

City

State

Telephone

Email

Zip Code

3 Applicant's Legal Entity & Citizenship
an individual, please enter the country of citizenship.
an 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.
State, Country or Other
entity information:

Application For Recordal Of Insignia Under the Fastner Quality Act or
Renewal/Reactivation of Recordal
15 U.S.C. Section 1504 et seq. (15 C.F.R. Section 280.300 et seq.)
page 4 of 5

4 Request for Recordal
The applicant requests the USPTO to assign a unique alphanumeric designation for recordal on the Fastner
Insignia Register.
The applicant requests recordal of the mark on the Fastner 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.
U.S. Application
Serial Number

OR

U.S. Registration
Number

5 Request for Renewal
A Certificate of Recordal remains "active" for a period of five years from the date of issuance. The USPTO
must receive a complete renewal application no later than six months after the expiration of that five-year
term or any five-year renewal term (the 10th year, 15th year, etc.), for your Certificate of Recordal to maintain
an active status.
The applicant requests renewal of the applicant's Certificate of Recordal based on either:
Trademark Application
Serial Number
Trademark Registration
Number
Alphanumeric
Designation
A copy of the Certificate of Recordal is attached.

This collection of information is required under 15 U.S.C. Section 5401 et seq. and 15 C.F.R. Section 280.300 et seq. The public
submits the information in connection with requests to record or renew insignia under the Fastner 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 Fastner Quality Act or
Renewal/Reactivation of Recordal
15 U.S.C. Section 1504 et seq. (15 C.F.R. Section 280.300 et seq.)
page 5 of 5

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 filling 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. Section 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. Section 5401. The applicant will
comply with the applicable provisions of the Fastener Quality Act (15 U.S.C. Sections 5401 et seq.). the
undersigned has knowledge of the facts relevant to the application and possesses the authority to act on
the 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 forward slashes
(example: /John Smith/ ) and click the submit button to e-mail your information to tmfqa@uspto.gov,
if you are paying the prescribed fee with a line for deposit account with the USPTO. Please e-mail
us any attachments.
2. You may print, manually sign, and fax this form to 571.273.8950 or print, manually sign, scan, and
e-mail 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 e-mail 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 & Position or Title of Signer
Date

USPTO Deposit Account No.

Authorized User Signature

Submit by Email
Applicant

Print Form