Form PTO-158T Application for Reciprocal Recognition to Practice in Tr

OMB No. 0000-0000 Approval Expires 12/31/2011

United States Patent and Trademark Office

FORM PTO-158T
(Rev. April 20, 2009)

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 persons are 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 Section 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 cases. 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 cases. 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.)

STATE

ZIP CODE

CITY

STATE

ZIP CODE

CITIZENSHIP (country)

DATE OF BIRTH (month, day, year)

CITY

BUSINESS PHONE AND AREA CODE

HOME ADDRESS
HOME PHONE AND AREA CODE
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 made application for recognition to practice before the Unites States
Patent and Trademark Office in trademark cases, 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 registered and 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-158A

Rev: April 15, 2009

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 registered.
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 discipline, reprimand, suspension, expulsion or request to resign
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 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 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 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?

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 cases 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 an 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
cases. If you do not furnish the requested information, you will not be admitted to the registration examination or registered
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.

2.

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 morale, 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 registered practitioners pursuant to 37 CFR 11.11.
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.

To a court or adjudicative body in a proceeding when: (a) the agency or any component thereof; or (b) any
employee of the agency in his or her capacity, or (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 constitute 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 man-power
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 stature 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.