Humanitarian Award Contact Information

 
OMB 0651-00xx Approved for use through (date)
U.S. Patent and Trademark Office; U. S. DEPARTMENT OF COMMERCE
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Humanitarian Award Application
Contact Info Form
This information will be used to notify applicants if they are selected to win an award.
Applicant Name(s): _________________________________________________________
Mailing Address: ___________________________________________________________
Telephone: _______________________ Email: __________________________________
Preferred contact method: _________________________________

Disclaimers
Please initial to indicate you have read and accept the following terms and conditions: _____
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Except for this contact info form, all contents of this application will be made publicly
available. Do not include any information in your application that you want to remain
confidential, including trade secrets, unpublished patent application details, classified
material, or other confidential business information.

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Material submitted in this application may be used by the U.S. Patent & Trademark
Office for promotional, instructional, or other purposes. You hereby waive all objections
and claims to any use of your submission by the USPTO.

Signature: _______________________________________ Date: ___________________

It is estimated that the Humanitarian Award Application will take 4 hours to complete. Applying for the Award is required to obtain or retain
benefits. Please send any comments on the amount of time required to complete this form and/or suggestions for reducing the time burden to the
Chief Information Officer, USPTO, PO Box 1450, Alexandria, VA 22313-1450. DO NOT SEND APPLICATIONS TO THIS ADDRESS