G412: Join the List Survey

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A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure
to comply with an information collection subject to the requirements of the Paperwork Reduction Act of 1995, unless the information
collection has a valid OMB Control Number. The OMB Control Number for this information collection is 0651-0080. Public burden for this
survey is estimated to average 3 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the information collection. Send comments regarding this burden
estimate or any other aspect of this information collection, including suggestions for reducing this burden to the Office of the Chief
Administrative Officer, United States Patent and Trademark Office, P.O. Box 1450, Alexandria, VA 22313-1450 or email
InformationCollection@uspto.gov.

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* 1. Full Name

* 2. Email Address

* 3. Type of Event

* 4. Where is this event being held?
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* 5. Graduation Date (Month, Year)

* 6. What opportunity are you most interested in at the
USPTO?
Patent Examiner
Internships/Externships
N/A
Other (please specify)

* 7. Would you like to sign up for our emailing list to
receive more information about career opportunities and
future events?
Yes
No

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Privacy Act Statement
The United States Patent and Trademark Office (USPTO) collects this information under authority of 35 U.S.C.
2(b)(2). The information you provide will be used to register to participate in Agency-sponsored events and
programs designed to disseminate information to the public on topics related to patents and trademarks. This
system includes information about individuals who have requested participation in an Agency-sponsored event
or program. The information is protected from disclosure to third parties in accordance with the Privacy Act.
However, routine uses of this information may include disclosure to the following: to non-Federal personnel
under contract to the Agency; to a court for adjudication and litigation; to the Department of Justice for
Freedom of Information Act (FOIA) assistance; to members of Congress; and to National Archives and Records
Administration. If you do not furnish the requested information, the USPTO may not be able to process your
request for participation in the event or program. The applicable Privacy Act System of Records Notice for this
information request is PAT-TM-19, Dissemination Events and Registrations: Federal Register vol. 71 December
27, 2006, page 77739, available at https://www.federalregister.gov/documents/2006/12/27/E6-22122/privacy-actof-1974-system-of-records.