Form PTO-107S Mandatory Survey: Data Sheet - Register of Patent Attorn

U.S. PATENT AND TRADEMARK OFFICE

OMB No. 0651‐0012 | Approved through 12/31/2017 | FORM PTO‐107S

MANDATORY SURVEY
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
FOR USPTO USE ONLY
 Mr.  Ms.
CORRESPONDENCE/
BUSINESS ADDRESS
(street, bldg., suite,
etc.) This address will
be used for official
correspondence.

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

REGISTRATION NUMBER

CORRESPONDENCE/BUSINESS CITY

CORRESPONDENCE/BUSINESS STATE

CORRESPONDENCE/BUSINESS COUNTRY

CORRESPONDENCE/BUSINESS ZIP CODE

PHONE NUMBER (daytime)

E-MAIL (primary)

E‐MAIL (secondary)

CITIZENSHIP (country)

DATE OF BIRTH (month, day, year)

ALTERNATE/HOME ADDRESS

ALTERNATE/HOME PHONE NUMBER

ALTERNATE/HOME CITY

1.

ALTERNATE/HOME STATE

Do you wish to remain on the register?  YES

ALTERNATE/HOME COUNTRY

ALTERNATE/HOME ZIP CODE

 NO

If "NO", do not complete items 3 through 7. Sign, date and return this Data Sheet
2.

Registration Status:  ATTORNEY

 AGENT

3.

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: __________________________________________________________________________________________________________

4.

 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.

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.

6.

 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).

7.

 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)).
8.

Signature of Applicant

Date

Page 2 of 2

OMB No. 0651‐0012 | Approved for use through 12/31/2017 | FORM PTO‐107S

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:
1.

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.

2.

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.

3.

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.

4.

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).

5.

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.

6.

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)).

7.

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.

8.

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.

9.

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.