Form PTO-275 Undertaking under 37 CFR 11.10(b)

U.S. PATENT AND TRADEMARK OFFICE

OMB No. 0651‐0012 | Approved through 09/30/2014 | FORM PTO‐275

UNDERTAKING UNDER 37 CFR § 11.10(b)

1. NAME  Mr.  Ms.

Last Name

First Name

Middle Name

FOR USPTO USE ONLY

2. POSITION HELD AT USPTO

3. DATE EMPLOYED BY USPTO

4. DATE OF SEPARATION OR RESIGNATION FROM USPTO

5. ASSIGNED TO THE FOLLOWING BUSINESS UNIT(s). List relevant Offices or Technology Centers.

Office or Technology Center

From

To

Director (Office or Technology Center)

I hereby agree to not knowingly act as an agent or attorney for, or otherwise represent, or assist in any manner the representation of, any other person before the Office, in connection with any particular patent or patent application, in which I participated personally and substantially as an employee of the Office; and I hereby agree to not knowingly act within two years after terminating employment by the Office as an agent or attorney for, or otherwise represent, or assist in any manner the representation of any other person before the Office, in connection with any particular patent or patent application, if such patent or patent application was pending under my official responsibility as an officer or employee within a period of one year prior to the termination of such responsibility.

6. REINSTATEMENT  ENCLOSED PLEASE FIND FORM PTO-107R – REINSTATEMENT DATA SHEET

I certify that each and every statement or representation in this Undertaking is true and correct. A willfully false statement or certification is a criminal offense and is punishable by law (18 U.S.C. § 1001).

6.

Signature of Former Employee

Date

Page 2 of 2	OMB No. 0651‐0012 | Approved for use through 09/30/2014 | FORM PTO‐275
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 §§ 11.5 through 11.11. This information is used by the public to register to practice before the United States Patent and Trademark Office (USPTO) and by the USPTO to determine the eligibility of the applicant to apply to register to practice before the USPTO. 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 admit you to the registration examination or register you to practice before the USPTO. 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 required 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. DO NOT SEND FEES OR COMPLETED FORMS TO THIS ADDRESS.
PRIVACY ACT STATEMENT The Privacy Act of 1974 (P.L. 93-579) requires that you be given certain information in connection with your submission of the attached form related to a patent application or patent. Accordingly, pursuant to the requirements of the Act, please be advised that: (1) the general authority for the collection of this information is 35 U.S.C. 2(b)(2); (2) furnishing of the information solicited is voluntary; and (3) the principal purpose for which the information is used by the U.S. Patent and Trademark Office is to process and/or examine your submission related to a patent application or patent. If you do not furnish the requested information, the U.S. Patent and Trademark Office may not be able to process and/or examine your submission, which may result in termination of proceedings or abandonment of the application or expiration of the patent. The information provided by you in this form will be subject to the following routine uses: The information on this form will be treated confidentially to the extent allowed under the Freedom of Information Act (5 U.S.C. 552) and the Privacy Act (5 U.S.C 552a). Records from this system of records may be disclosed to the Department of Justice to determine whether disclosure of these records is required by the Freedom of Information Act. A record from this system of records may be disclosed, as a routine use, in the course of presenting evidence to a court, magistrate, or administrative tribunal, including disclosures to opposing counsel in the course of settlement negotiations. A record in this system of records may be disclosed, as a routine use, to a Member of Congress submitting a request involving an individual, to whom the record pertains, when the individual has requested assistance from the Member with respect to the subject matter of the record. A record in this system of records may be disclosed, as a routine use, to a contractor of the Agency having need for the information in order to perform a contract. 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). A record related to an International Application filed under the Patent Cooperation Treaty in this system of records may be disclosed, as a routine use, to the International Bureau of the World Intellectual Property Organization, pursuant to the Patent Cooperation Treaty. A record in this system of records may be disclosed, as a routine use, to another federal agency for purposes of National Security review (35 U.S.C. 181) and for review pursuant to the Atomic Energy Act (42 U.S.C. 218(c)). A record from this system of records may be disclosed, as a routine use, to the Administrator, General Services, or his/her designee, during an inspection of records conducted by GSA as part of that agency’s responsibility to recommend improvements in records management practices and programs, under authority of 44 U.S.C. 2904 and 2906. Such disclosure shall be made in accordance with the GSA regulations governing inspection of records for this purpose, and any other relevant (i.e., GSA or Commerce) directive. Such disclosure shall not be used to make determinations about individuals. A record from this system of records may be disclosed, as a routine use, to the public after either publication of the application pursuant to 35 U.S.C. 122(b) or issuance of a patent pursuant to 35 U.S.C. 151. Further, a record may be disclosed, subject to the limitations of 37 CFR 1.14, as a routine use, to the public if the record was filed in an application which became abandoned or in which the proceedings were terminated and which application is referenced by either a published application, an application open to public inspection or an issued patent. A record from this system of records may be disclosed, as a routine use, to a Federal, State, or local law enforcement agency, if the USPTO becomes aware of a violation or potential violation of law or regulation.