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

OMB No. 0651-0012 Approval Expires 09/30/2014

FORM PTO - 107A

UNITED STATES PATENT AND TRADEMARK OFFICE

(Rev. February 21, 2013)

DATA SHEET - REGISTER OF PATENT ATTORNEYS AND AGENTS

You must provide a correspondence/business name, address and telephone number in the blocks
below. Government employees must provide the name and address of the department or
Government agency in the correspondence/business name, address and telephone number. 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.

LEGAL NAME

Last Name

COMPLETE ALL LINES
First Name

FOR USPTO OFFICE USE ONLY

Middle Name

REGISTRATION NUMBER

Mr.
Ms.
CORRESPONDENCE / BUSINESS NAME (employer, corporation, law firm, or U.S. Government agency, etc.)

CORRESPONDENCE / BUSINESS ADDRESS (street, building, suite, etc.)
CITY

STATE

ZIP CODE

PRIMARY E-MAIL

BUSINESS PHONE

SECONDARY E-MAIL

HOME ADDRESS
STATE

CITY

ZIP CODE

CITIZENSHIP (country)

HOME PHONE

DATE OF BIRTH (month, day, year)

1. Registration Status:

ATTORNEY

AGENT

2. 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:
3.

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.

4.

YES

NO

5.

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.
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).

6.

YES

NO

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

FOR UNITED STATES PATENT AND TRADEMARK
OFFICE USE ONLY

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)).

AGENT: ___________________________________
ATTORNEY:________________________________

(See reverse side of form for Privacy Act Statement) Signature of Practitioner

Date

FORM PTO - 107A (Rev. February 21, 2013)

Page 2

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 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, or if you are registered, may remove your name from the register of patent attorneys or agents
pursuant to 37 CFR §§ 10.11 and 11.10. This form is estimated to take 20 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, Director, 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 forms PTO-158, PTO-275 and PTO-1209. 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 and 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 registration to
practice before the United States Patent and Trademark Office in patent matters. If you do not furnish the requested information, you will not
be admitted to the registration examination, registered or reinstated to practice before the United States Patent and Trademark Office.
The information provided by you in this form will be subject to the following routine uses:
1.

Information from PTO-158 may be published by the United States Patent and Trademark Office in the Official Gazette to solicit
information tending to affect your eligibility on moral, ethical, or other grounds for registration pursuant to 37 CFR § 11.7. Information
from PTO-275 may be published to provide the public with a roster of registered practitioners pursuant to 37 CFR § 11.11.

2.

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 United States 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.

Disclosure may be made 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 constituent 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 to5 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 manpower 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, 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 statute or rule,
regulation or order issued pursuant thereto, if the information disclosed is relevant to any enforcement, regulatory, investigative, or
prospective responsibility of the receiving entity.