Form PTO-2224 Form to Collect Data from Public Users

PTO-2224 (7/2006)
Approved for use through 06/30/2009. OMB 0651-0041
U.S. Patent and Trademark Office; U.S. DEPARTMENT OF COMMERCE
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.

FORM TO COLLECT DATA FROM PUBLIC SEARCHERS

In order for the Office of Security to issue a SMART card, it is essential that each intended user
provide the information, as requested below.
Once the appropriate information is received and final processing completed, you will be notified
and provided instructions for receiving your Smart card.
Should you have any questions or require additional assistance, please do not hesitate to contact
the Security Service Center at (571) 272-8000.

First Name:

Last Name:

Date of Birth:

Middle Initial:

Last five digits of SSN:____________________________
(Format: 09-16-1958)

Place of Birth:
(Indicate City and two-letter code for State; if not in the U.S. then indicate Country)

Home #:
Work #.:

Signature:

Today’s Date:
This collection of information is authorized by 5 U.S.C. § 301, 35 U.S.C. § 2, 41 CFR Part 102-81, and E.O. 9397 and is used by the
public to apply for (and by the USPTO to issue) security identification badges for public search room users. The information on this
form will be treated confidentially to the extent allowed under the Freedom of Information Act (FOIA) and the Privacy Act.
Submission of this information is voluntary; however, if you do not provide this information, you will not be issued a security
identification badge. The USPTO will use this information primarily to issue official identification badges to individuals accessing
USPTO facilities and to maintain a record of all holders of these identification badges, to renew and recover expired badges, and to
identify badges that are lost or stolen. Routine uses of the information you supply may also include disclosure to law enforcement
authorities, to your employer, or to organizations with which you claim affiliation. This information may also be disclosed to Federal,
state, or local agencies in support of their statutory or regulatory mission or enforcement duties; to a court, magistrate, or
administrative tribunal; to members of Congress or their staffs responding to requests from their constituents; to the medical advisor
of an individual requesting access to records containing medical information; to the Office of Management and Budget in connection
with the review of private relief legislation; to the Department of Justice in connection with a FOIA request; to a contractor in the
performance of their duties; to the Office of Personnel Management for personnel studies; and to the General Services
Administration in connection with their records management responsibilities under the authority of 44 U.S.C. §§ 2904 and 2906. This
form is estimated to take 5 minutes to complete, including gathering the necessary information, preparing the form, and submitting
the request to the USPTO Security Office. 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 Director of the Security Office, USPTO, P.O. Box 1450, Alexandria, VA
22313-1450

(See reverse for additional information regarding the SMART card)

SMART card holder responsibilities:
Following is additional information regarding the safeguarding of the SMART card that you will
be issued. By not properly adhering to the information provided below, your card will be
immediately deactivated.

This badge is only issued for use in our Public Search Facility/Area.
I certify that I will only use this badge for search purposes.

1. WEARING/DISPLAYING: As the SMART card will also be considered the USPTO
official identification, the front of the card (photo or type side) must be prominently displayed at
all times. When displaying the card, it will be worn between the neck and waist.
2. SAFEGUARDING: When not wearing the SMART card or the card is not in your physical
custody, it will be secured against loss or theft in the same or similar manner, as you would
protect your purse or wallet against loss or theft.
3. USE: The SMART card will be used for official purposes only and it will not be loaned,
given or otherwise allowed by any other person to use the card for any purpose.
4. REPORTING LOSS OR THEFT: The loss or theft of the SMART card will be reported to
the Office of Security at (571) 272-8000. If the lost or stolen card is subsequently recovered, it
will be promptly returned to the Office of Security.
5. RETURN OF CARD: The SMART card will be immediately returned to the Office of
Security when you are no longer searching, or upon request by the Office of Security.
6. REISSUE SMART CARD: If you have lost your smart card, in order to obtain a
replacement a $15.00 fee will be needed by personal check or money order. Make your checks
or money orders out to Director USPTO.