Form PTO-158LS Application for Registration in the USPTO Law School Pro

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OED 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 and PTO-275. 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 cases. If you do not furnish the requested information, you will not be
admitted to the registration examination or registered to practice before the United States Patent and Trademark
Office.
The information provided by you in these forms 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 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 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. 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 to 5 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,
or 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 stature or rule, regulation, or order issued pursuant thereto, if the information disclosed is
relevant to any enforcement, regulatory, investigative, or prosecutive responsibility of the receiving entity.

OMB No.

FORM PTO-158LS (Rev. October 23,2009

Approval Expires 12/31/2010
THIS SPACE FOR UNITED STATES
PATENT AND TRADEMARK OFFICE
USE ONLY

United States Patent and Trademark Office

APPLICATION FOR REGISTRATION TO PRACTICE
BEFORE THE UNITED STATES PATENT AND TRADEMARK OFFICE
Under the Paperwork Reduction Act of 1995, no persons are 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 Sections 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 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 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. DO NOT SEND FEES
OR COMPLETED FORMS TO THIS ADDRESS.
SEND TO: Mail Stop OED, United States Patent and Trademark Office, PO Box 1450, Alexandria, VA 22313-1450

First Name

1a) Legal Name
1c) ADDRESS:

Middle Name

Last Name

Law School Clinic address

(street, building, suite, etc.)

1d)

2.

CITY

1e)

STATE

CITIZENSHIP (country)

FOR ALIENS
ONLY

1f) ZIP CODE

3. DATE OF BIRTH (month, day, year)

5. VISA CLASSIFICATION 6. PERMANENT RESIDENT OF THE UNITED STATES

YES Attach copy of both sides of
documentation of permanent residence
NO

1g) DAYTIME Area Code & Phone Number

4. PLACE OF BIRTH (City, State, Country)
7. ALIEN REGISTRATION NUMBER

You are required to update the foregoing information promptly upon any change. Select and check all the following that apply.
Applicants should carefully review the General Requirements Bulletin for detailed instructions on completing this application.

8

Are you presently a Registered Agent?
No (go to #9)
- OR -

Yes. Please see #8a.

8a. My Registration No. is _________________________

9. EDUCATION: Law School information:
Law School Clinic

Trademark or Patent Clinic

Semester(s) Participating

Miscellaneous Information

Upon the basis of the foregoing information and any attached documents, I hereby apply for registration to practice in
trademark and/or patent cases before the United States Patent and Trademark Office. I certify that each and every statement
or representation inthis 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].)
10.
Signature of Applicant

Date