Form Application for Re Application for Re PTO 158

U.S. PATENT AND TRADEMARK OFFICE

OMB No. 0651‐0012 | Approved through 12/31/2017 | FORM PTO‐158

APPLICATION FOR REGISTRATION TO PRACTICE
BEFORE THE UNITED STATES PATENT AND TRADEMARK OFFICE
1A. LEGAL NAME

Last Name

First Name

 Mr.  Ms.
1B. NAME SHOWN ON VALID GOVERNMENT ID

1C. ADDRESS
(street, bldg.,
suite, etc.) This
address will be
used for official
correspondence.

Middle Name

FOR USPTO USE ONLY

 same as above

Employer, corporation, law firm, U.S. Government agency. Indicate if student or unemployed.

 REASONABLE ACCOMMODATION
REQUEST ATTACHED

1D. CITY

1E. STATE

1H. PHONE NUMBER (daytime)

1I. E-MAIL (primary)

1J. E‐MAIL (secondary)

2. CITIZENSHIP (country)

3. DATE OF BIRTH (month, day, year)

4. PLACE OF BIRTH (City, State, Country)

FOR
ALIENS
ONLY 

6. PERMANENT RESIDENT OF THE UNITED STATES
 YES
Attach copy of both sides of
 NO
permanent residence documentation

7. ALIEN REGISTRATION NUMBER

5. VISA CLASSIFICATION

1F. COUNTRY

1G. ZIP CODE

You are required to update the foregoing information promptly upon any change. Check all the following that apply. Applicants should carefully
review the General Requirements Bulletin for detailed instructions on completing this application.
8A.

APPLICATION FEE: (PLEASE REFER TO THE GENERAL REQUIREMENTS BULLETIN AND 37 CFR § 11.7)


OR

8B.

OR


37 CFR § 11.7(d)(1).

 37 CFR § 11.7(d)(2).

 37 CFR § 11.7(d)(3).

I passed an examination on _____ / _____ / ________. Enclosed is the required registration fee of $100.00 (37 CFR § 1.21(a)(2)) and a
completed data sheet.

PREVIOUSLY APPLIED FOR ADMISSION:



I previously applied for admission to the registration examination or requested the Office of Enrollment and Discipline to evaluate my
scientific and technical qualifications. Enclosed is my application fee under 8A, along with the registration exam fee under 8B.
Date of Previous Application: _____ / _____ / ________

12.

Enclosed is the application fee under 8A, above.

PREVIOUSLY PASSED EXAMINATION:


11.

I will utilize a commercial test administration service. Enclosed is the Government registration examination fee of $200 for test
administration by a commercial entity. 37 CFR § 1.21(a)(1)(ii)(A). See the General Requirements Bulletin for information about fees
that may be charged by the commercial test administration service.
I request USPTO test administration. Enclosed is the Government registration examination fee of $450.00 for test administration by
USPTO. 37 CFR § 1.21(a)(1)(ii)(B).

WAIVER OF EXAMINATION: I AM A FORMER USPTO EMPLOYEE AND SATISFY THE REQUIREMENTS OF:


10.

Enclosed is the $1,600.00 fee set forth in 37 CFR § 1.21(a)(10).

REGISTRATION EXAMINATION FEE:



9.

Enclosed is the non‐refundable $40.00 application fee set forth in 37 CFR § 1.21(a)(1)(i).

Name on Application, if different __________________________________

PREVIOUSLY REGISTERED TO PRACTICE:



I was previously registered to practice in patent cases before the United States Patent and Trademark Office as an attorney or agent.
Registration No. _______________________________

13.

BAR MEMBERSHIP:



I am a member in good standing of the bar of the highest court of a State or Territory of the United States. A list of all said courts and
corresponding bar membership numbers(s) follows:
_____________________________________________________________________________________________________________

Page 2 of 3

OMB No. 0651‐0012 | Approved for use through 12/31/2017 | FORM PTO‐158

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 registration.
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 registration or in disciplinary proceedings, should you become
registered. See 37 CFR §§ 11.7(a)(2)(ii), 11.19, and 11.801.
14.

 YES

 NO

Have you ever been disciplined, reprimanded, suspended, expelled, or agreed to surrender a license or have any
charges ever been proffered against you in connection with your practice before any Federal or State court, municipal
bureau, commission, office, or agency of any kind or character?

15.

 YES

 NO

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.)

16.

 YES

 NO

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
or in time to avoid discipline, reprimand, suspension, or expulsion for conduct involving dishonesty, fraud,
misrepresentation, or deceit?

17.

 YES

 NO

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?

18.

 YES

 NO

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

19.

 YES

 NO

Have you ever resigned or quit a job when you were under investigation or inquiry for conduct which could have been
considered as involving dishonesty, fraud, misrepresentation, deceit, or violation of Federal or State laws or regulations,
or after receiving notice or been advised of possible investigation, inquiry, or disciplinary action for such conduct?

20.

 YES

 NO

Have you ever been discharged from military service under conditions “other than honorable,” or by reason of the
sentence of a Court Martial or being dropped from the rolls?

21.

 YES

 NO

Are you delinquent on any State or Federal debt? (Include delinquencies arising from Federal or State taxes, loans,
overpayment of benefits, and other debts to the U.S. Government and defaults on Federally guaranteed or insured
loans such as student and home mortgage loans.)

22.

EDUCATION: List all degrees conferred. Attach any required documentation as discussed in the General Requirements Bulletin. If you applied
previously for an exam, please see the General Requirements Bulletin section titled “REAPPLYING TO TAKE THE EXAMINATION” for what you
must submit.

Degree Received as indicated on Transcript

College

Date Received

Major Subject as indicated on Transcript

Upon the basis of the foregoing information and any attached documents, I hereby apply for registration to practice in patent 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).
23.

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

Page 3 of 3

OMB No. 0651‐0012 | Approved for use through 12/31/2017 | FORM PTO‐158

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:
1.

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.

2.

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.

3.

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.

4.

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).

5.

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.

6.

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)).

7.

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.

8.

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.

9.

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.