Form PTO-158A Application for Registration to Practice Before the Unit

OMB No. 0651-0012 Approval Expires 09/30/2014
FORM PTO-158A (Rev. Feb. 21, 2013)

United States Patent and Trademark Office

APPLICATION FOR REGISTRATION TO PRACTICE BEFORE THE
UNITED STATES PATENT AND TRADEMARK OFFICE
UNDER 37 CFR § 11.6(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 §§ 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 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 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 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.)

E-mail (primary)

Correspondence / Business Address (street, building, suite, etc.)

E-mail (secondary)

City

State

Zip Code

Business Phone

State

Zip Code

Home Phone

Home Address
City
Citizenship

Date of Birth (month, day, year)

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 (37 CFR § 1.21(a)(1)(i))

2.

☐ YES ☐ NO

Have you previously applied for registration to practice before the United States Patent and
Trademark Office, or have you ever received from the Office of Enrollment and Discipline an evaluation of your
scientific and technical qualifications?

If “YES”, provide the date and name on the application if different from above: ___________________________________________
3.

☐ YES ☐ NO

Were you ever registered to practice in patent cases before the U.S. Patent and Trademark Office as an
attorney or agent? If “YES”, include your Registration Number:______________________________________

4a. I am registered and in good standing before the Patent Office of _____________________________________________________.
A certificate of good standing

☐ is attached ☐ was previously submitted.

4b. In accordance with 37 CFR § 11.6(c), provide evidence establishing that the Patent Office of the country in which you reside and
practice allows substantially reciprocal privileges to those admitted to practice before the United States Patent and Trademark Office.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
4c. Parties under whom United States patent prosecution experience, if any, was gained.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

FORM PTO-158A (Rev. Feb. 21, 2013)

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 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 under 37 CFR § 10.22 should you become registered.

☐ YES ☐ NO

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
th
include any misdemeanor before your 16 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 a
request to resign, discipline, reprimand, suspension, or expulsion 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 for any violation of Federal or State laws or regulations?

☐ YES ☐ NO

9.

Have you ever been fired or discharged from any job for conduct involving dishonesty, fraud,
misrepresentation, deceit, or been asked to resign or quit for conduct involving dishonesty, fraud,
misrepresentation, deceit, or for 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 conduct which could
have been considered as involving dishonesty, fraud, misrepresentation, deceit, or for any violation of Federal
or State laws or regulations, or after receiving notice or being advised of possible investigation, inquiry, or
disciplinary action for such conduct?

☐ YES ☐ NO

11. 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?

☐ YES ☐ NO

12. 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.)

13. EDUCATION: List all degrees conferred in the blocks below. Attach to this application any required documentation to complete
your application for registration. Refer to the General Requirements Bulletin. Any Official transcripts previously filed in a prior
application for registration or the registration examination need not be resubmitted unless changed since the prior submission.
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 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)).
14. 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