PTO-107A Data Sheet - Register of Patent Attorneys and Agents

U.S. PATENT AND TRADEMARK OFFICE

OMB No. 0651‐0012 | Approved through 09/30/2014 | FORM PTO‐107A

DATA SHEET - REGISTER OF PATENT ATTORNEYS AND AGENTS

You must provide a correspondence/business name, address and telephone number in the boxes below. Government employees must provide the name and address of the department or Government agency in the correspondence/business name, address and telephone number boxes. This will be published in the Government publication Attorneys and Agents Registered to Practice Before the United States Patent and Trademark Office. Also provide your home address and telephone number. Only one correspondence address and telephone number will be published. COMPLETE ALL LINES

LEGAL NAME Last Name First Name Middle Name  Mr.  Ms.

FOR USPTO USE ONLY

REGISTRATION NUMBER

E-MAIL (primary)

E‐MAIL (secondary)

CITIZENSHIP (country)

DATE OF BIRTH (month, day, year)

PLACE OF BIRTH (City, State, Country)

CORRESPONDENCE/BUSINESS NAME Employer, corporation, law firm, U.S. Government agency. Indicate if student or unemployed

CORRESPONDENCE/ BUSINESS ADDRESS (street, bldg., suite, etc.) This address will be used for official correspondence.

BUSINESS NUMBER

BUSINESS CITY

BUSINESS STATE

BUSINESS COUNTRY

BUSINESS ZIP CODE

HOME ADDRESS

HOME NUMBER

HOME CITY

HOME STATE

HOME COUNTRY

HOME ZIP CODE

Registration Status:  ATTORNEY  AGENT

If you are an attorney, please list all States of the United States in which you are a member in good standing of the bar of the highest court of the State: __________________________________________________________________________________________________________

 YES

 NO

In the last five (5) years, have you been suspended or disbarred from practice on ethical grounds by any duly constituted authority of a State of the United States, or in the case of a practitioner who resides in a foreign country or is registered under 37 CFR § 11.6(c) by any duly constituted authority of the country in which the practitioner resides? If YES, please attach a statement explaining when, where and the grounds for the disbarment or suspension. Do not include any misdemeanor before your 16th birthday or traffic violations for which the fine was $100 or less.

 YES

 NO

In the last five (5) years, have you been convicted of a felony or misdemeanor (other than a traffic violation) by any federal, State or other law enforcement authority? If YES, please attach a statement giving the date, charge, and place of the offense and an explanation of the facts and circumstances leading to the conviction.

 YES

 NO

Are you an employee of the United States Government? PLEASE NOTE: U.S. Government employees are not available to accept private clients or to represent clients other than their agency before the United States Patent and Trademark Office. 18 U.S.C. § 205; 37 CFR §§ 11.10(d) and (e).

 YES

 NO

Are you a former patent examiner of the United States Patent and Trademark Office?

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

Signature of Applicant

Date

Page 0 of 3	OMB No. 0651‐0012 | Approved for use through 09/30/2014 | FORM PTO‐107A
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.