PTO-158T Application for Recognition to Practice before the USTPO

U.S. PATENT AND TRADEMARK OFFICE						OMB No. 0651‐0012 | Approved through 09/30/2014 | FORM PTO‐158T
APPLICATION FOR RECOGNITION TO PRACTICE BEFORE THE UNITED STATES PATENT AND TRADEMARK OFFICE UNDER 37 CFR § 11.14(c) BY A FOREIGN RESIDENT
1A. LEGAL NAME  Mr.  Ms.			Last Name	Middle Name				First Name	FOR USPTO USE ONLY
1B. ADDRESS (street, bldg., suite, etc.) This address will be used for official correspondence.			Employer, corporation, law firm, U.S. Government agency. Indicate if student or unemployed.
1C. CITY					1D. STATE		1E. COUNTRY		1F. ZIP CODE
1G. PHONE NUMBER (daytime)					1H. E-MAIL (primary)				1I. E‐MAIL (secondary)
2. CITIZENSHIP (country)					3. DATE OF BIRTH (month, day, year)				4. PLACE OF BIRTH (City, State, Country)
You are required to update the foregoing information promptly upon any change. Check all the following that apply.
5.	APPLICATION FEE: (PLEASE REFER TO THE GENERAL REQUIREMENTS BULLETIN AND 37 CFR § 11.7)
	OR	Enclosed is the non‐refundable $40.00 application fee set forth in 37 CFR § 1.21(a)(1)(i).
		Enclosed is the $1,600.00 fee set forth in 37 CFR § 1.21(a)(10).
6.	PREVIOUSLY APPLIED FOR RECOGNITION:
		I previously applied for recognition to practice before the United Stated Patent and Trademark Office in trademark matters or received from the Office of Enrollment and Discipline an evaluation of my qualifications. Enclosed is my application fee under 5. Date of Previous Application: _____ / _____ / ________ Name on Application, if different __________________________________
7.	BASIS FOR RECOGNITION:
		I am in good standing before the Trademark Office of: (list all that apply) _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________
8.	BAR MEMBERSHIP:
		I am an active attorney in good standing in each of the following courts or jurisdictions. Please provide the corresponding bar membership numbers and enclose a proof of your status as an attorney. _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________

Page 0 of 4					OMB No. 0651‐0012 | Approved for use through 09/30/2014 | FORM PTO‐158T
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.
		 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?
		 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.)
		 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?
		 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?
		 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
		 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?
		 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?
		 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.)
Upon the basis of the foregoing information and any attached documents, I hereby apply for recognition to practice in trademark 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).
	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 0 of 4	OMB No. 0651‐0012 | Approved for use through 09/30/2014 | FORM PTO‐158T
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.