PTO 158 Application for Registration to Practice before the Unit

OMB No. 0651-0012 Approval Expires 06/30/2013

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

United States Patent and Trademark Office

APPLICATION FOR REGISTRATION TO PRACTICE
BEFORE THE UNITED STATES PATENT AND TRADEMARK OFFICE

THIS SPACE FOR UNITED STATES PATENT
AND TRADEMARK OFFICE USE ONLY

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 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, P.O. Box 1450, Alexandria, VA 22313-1450

First Name

1a. Legal Name

Middle Name

Last Name

Reasonable
Accommodations
Request Attached

1b. Name shown on
valid Government ID
1c. ADDRESS:

Employer, corporation, law firm, U. S. Government agency. Indicate if student or unemployed.

ADDRESS
(street, building,
suite, etc.)
1d. CITY
1h. PRIMARY E-MAIL

2.

1f. ZIP CODE

1e. STATE
1i. SECONDARY E-MAIL

CITIZENSHIP (country)

FOR ALIENS
ONLY

1g. DAYTIME Area Code & Phone Number

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

5. VISA CLASSIFICATION 6. PERMANENT RESIDENT OF THE UNITED STATES
Attach copy of both sides of
ES

NO

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

documentation of permanent
residence

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.

8b.

9.

10.
11.
12.
13.
14.

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).

Registration Examination Fee:
I will utilize a commercial test administration service. Enclosed is the Government registration examination fee of
$200.00 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 the USPTO. 37 CFR §1.21(a)(1)(ii)(B)
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)
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.
Reinstatement: I am applying for reinstatement, or as a former government employee, for a change from inactive to
active status. Enclosed is any required fee under 37 CFR §1.21.
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:_______________________________
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 __________________________
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 number(s) follows: __________________________
_______________________________________________________________________________________________

FORM PTO-158 (Rev. February 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, should you become registered. See 37 CFR §§ 11.7(a)(2)(ii), 11.19, and 11.801.
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 county or municipal law,
regulation or ordinance? (Do not include any misdemeanor before your 16th 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 discipline, reprimand, suspension, expulsion or request to resign
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 any violation of Federal or State laws or
regulations?

YES

NO

19. Have you ever been fired or discharged from any job, or have 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 boxes 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

Major Subject as
indicated on Transcript

Date Received

Upon the basis of the foregoing information and any attached documents, I hereby apply for registration to practice in patent
cases 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