Form PTO-158 Application for Registration to Practice Before the Unit

OMB No. 0651-0012 Approval Expires 09/30/2014
United States Patent and Trademark Office

FORM PTO-158 (Rev. Feb. 21, 2013)

APPLICATION FOR REGISTRATION TO PRACTICE
BEFORE THE UNITED STATES PATENT AND TRADEMARK OFFICE
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 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.
SEND TO: Mail Stop OED, United States Patent and Trademark Office, P.O. Box 1450, Alexandria, VA 22313-1450

1a. Legal Name

First Name

Middle Name

THIS SPACE FOR UNITED STATES PATENT
AND TRADEMARK OFFICE USE ONLY

Last Name

Reasonable
Accommodation
Request Attached

1b. Name shown on
valid Government ID
Employer, corporation, law firm, U.S. Government agency. Indicate if student or unemployed.

1g. Phone Number (daytime)

1c. Address
(street, bldg.,
suite, etc.)

1h. E-mail (primary)

1d. City

1e. State

2. Citizenship (country)

3. Date of Birth (month, day, year)

FOR ALIENS
ONLY

5. Visa Classification

1f. Zip code

6. Permanent Resident of the United States
☐ YES Attach copy of both sides of
☐ NO permanent residence documentation

1i. E-mail (secondary)
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.
8a.
Application Fee: (Please refer to the General Requirements Bulletin and 37 CFR § 11.7)
☐ Enclosed is the non-refundable $40.00 application fee set forth in 37 CFR § 1.21(a)(1)(i).
OR
☐ Enclosed is the $1,600.00 fee set forth in 37 CFR § 1.21(a)(10).
8b.
Registration Examination Fee:
☐ I will utilize a commercial test administration service. Enclosed in the Government registration examination fee of $200
for test administration by a commercial entity. 37 CFR § 1.21(a)(1)(ii)(A)
☐ I request USPTO test administration. Enclosed is the Government registration examination fee of $450.00 for test
administration by USPTO. 37 CFR § 1.21(a)(1)(ii)(B)
9.
Waiver of Examination: I am a former USPTO employee and satisfy the requirements of:
☐ 37 CFR § 11.7(d)(1). Enclosed is the applicable fee under either 37 CFR § 1.21(a)(1)(i) OR 37 CFR § 1.21(a)(10)
☐ 37 CFR § 11.7(d)(2). Enclosed is the applicable fee under either 37 CFR § 1.21(a)(1)(i) OR 37 CFR § 1.21(a)(10)
☐ 37 CFR § 11.7(d)(3). Enclosed is the applicable fee under either 37 CFR § 1.21(a)(1)(i) OR 37 CFR § 1.21(a)(10)
10. ☐ Passed Examination: I passed an examination on _____________________. Enclosed is the required registration fee
of $100.00 (37 CFR § 1.21(a)(2)) and a completed data sheet.
11. ☐ Reinstatement: I am applying for reinstatement, or as a former government employee, for a change from inactive to
active status. Enclosed is my required fee under 37 CFR § 1.21.
12. ☐ I previously applied for admission to the registration examination or requested the Office of Enrollment and Discipline to
evaluate my scientific and technical qualifications.
Date of Previous Application: ____________________ Name on Application, if different: _______________________________
13. ☐ I was previously registered to practice in patent cases before the United States Patent and Trademark Office as an attorney
or agent. If “YES”, my Registration No. is _______________________________
14. ☐ BAR MEMBERSHIP. I am a member in good standing of the bar of the highest court of a State or Territory of the United States.
A list of all said courts and corresponding bar membership numbers(s) follows:

_______________________________________________________________________________________________

_______________________________________________________________________________________________

FORM PTO-158 (Rev. Feb. 21, 2013)

Page 2

BACKGROUND INFORMATION: Candor and truthfulness are significant elements of fitness relevant to practice before the United States
Patent and Trademark Office. You should, therefore, provide the Office of Enrollment and Discipline with all available information, however
unfavorable, even if its relevance is in doubt, with regard to the questions asked below. For each question answered “YES,” provide a detailed
statement setting forth all relevant facts and dates along with verified copies of relevant documents. Your responses must be updated, as
necessary, prior to your registration. Any documents, evidence or proofs previously filed in a prior application need not be resubmitted
unless your response to a question must be changed. Failure to disclose the requested information may result in denial of registration
or in disciplinary proceedings under 37 CFR § 10.22, should you become registered.

☐ YES ☐ NO

15. Have any charges ever been preferred against you in connection with your practice before any Federal or State
court, or municipal bureau, commission, office or agency of any kind or character?

☐ YES ☐ NO

16. Have you ever been arrested, charged or held by Federal, State or other law enforcement authorities for any
violation of any Federal or State law, or any country or municipal law, regulation or ordinance? (Do not include
th
any misdemeanor before your 16 birthday or traffic violations for which the fine was $100 or less.)

☐ YES ☐ NO

17. Have you ever been disciplined, reprimanded, suspended, expelled or asked to resign or withdraw from any
educational institution, or have you resigned or withdrawn from any such institution in time to avoid a request to
resign or in time to avoid discipline, reprimand, suspension, or expulsion for conduct involving dishonesty, fraud,
misrepresentation, or deceit?

☐ YES ☐ NO

18. Have you ever been disciplined, reprimanded, or suspended in any job for conduct involving dishonesty, fraud,
misrepresentation, deceit, or for any violation of Federal or State laws or regulations?

☐ YES ☐ NO

19. Have you ever been fired or discharged from any job, or have you been asked to resign or quit for conduct
involving dishonesty, fraud, misrepresentation, deceit, or any violation of Federal or State laws or regulations?

☐ YES ☐ NO

20. Have you ever resigned or quit a job when you were under investigation or inquiry for conduct which could have
been considered as involving dishonesty, fraud, misrepresentation, deceit, or violation of Federal or State laws or
regulations, or after receiving notice or been advised of possible investigation, inquiry, or disciplinary action for
such conduct?

☐ YES ☐ NO

21. Have you ever been discharged from military service under conditions “other than honorable,” or by reason of the
sentence of a Court Martial or being dropped from the rolls?

☐ YES ☐ NO

22. Are you delinquent on any State or Federal debt? (Include delinquencies arising from Federal or State taxes, loans,
overpayment of benefits, and other debts to the U.S. Government and defaults on Federally guaranteed or
insured loans such as student and home mortgage loans.)

23. EDUCATION: List all degrees conferred in the blocks below. Attach to this application any required documentation to complete
your application for registration. Refer to the General Requirements Bulletin. If you applied previously for an exam, please see
the General Requirements Bulletin section titled “REAPPLYING TO TAKE THE EXAMINATION” for what you must submit.
Degree Received as
indicated on Transcript

College

Date Received

Major Subject as indicated
on Transcript

Upon the basis of the foregoing information and any attached documents, I hereby apply for registration to practice in patent matters
before the United States Patent and Trademark Office. I certify that each and every statement or representation in this 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)).

24. Signature of Applicant

Date

Mail completed application to:
Mail Stop OED, United States Patent and Trademark Office, P. O. Box 1450, Alexandria, VA 22313-1450