Pto 107r

OMB No. 0651‐0012 | Approved through 10/31/2024 | FORM PTO‐107R

U.S. PATENT AND TRADEMARK OFFICE

REINSTATEMENT
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
accordance with 37 CFR § 11.11(a). Only your correspondence/business 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

CORRESPONDENCE/BUSINESS PHONE NUMBER
(daytime)

E-MAIL (primary)

E‐MAIL (secondary)

CITIZENSHIP (country)

DATE OF BIRTH (month, day, year)

ALTERNATE/HOME ADDRESS

ALTERNATE/HOME CITY

1.

ALTERNATE/HOME PHONE NUMBER

ALTERNATE/HOME STATE

ALTERNATE/HOME COUNTRY

ALTERNATE/HOME ZIP CODE

REINSTATEMENT:



I am applying for reinstatement as a former government employee (administratively inactive). Enclosed is my fee set forth in
37 CFR § 1.21(a)(1)(i). Also enclosed is the Undertaking form.



I am applying for reinstatement from voluntary inactive to active under 37 CFR § 11.11(d)(6).



I am applying for reinstatement after having resigned under 37 CFR § 11.11(e).



I am applying for reinstatement of my limited recognition status. Enclosed is my fee set forth in 37 CFR § 1.21(a)(2)(ii).



I am applying for reinstatement after discipline. Enclosed is my fee set forth in 37 CFR § 1.21(a)(10).



I am applying for reinstatement after administrative suspension. Enclosed is my fee set forth in 37 CFR § 1.21(a)(9).

2.

Registration Status:
PATENT ATTORNEY
PATENT AGENT
LIMITED RECOGNITION
DESIGN ATTORNEY
DESIGN AGENT
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

In the last five (5) years, have you been convicted of a felony or misdemeanor (other than a non-criminal 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.

5.

 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 § 11.111.

6.

 YES

 NO

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

I hereby declare that all statements made herein of my own knowledge are true and that all statements made on information and belief are
believed to be true; and further that these statements were made with the knowledge that willful false statements and the like so made are
punishable by fine or imprisonment, or both, under 18 U.S.C. 1001.
7.

Signature of Applicant

Date

Page 2 of 2

OMB No. 0651‐0012 | Approved for use through 10/31/2024 | FORM PTO‐107R

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.