CPM Speaker Interest Form

OMB Control No.: 0651-0080

Expiration Date: 8/31/2018

Patents Customer Partnership Meetings (CPM)

Speaker Interests Form

We are interested in hearing from you. To participate as a CPM speaker, please fill out the form below. All items with “*” are required.

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*First Name:

*Last Name:

*E-mail Address:

*Telephone:

Best Time to Reach:

Job Title:

Company or Organization:

URL:

Which topic(s) are you interested in speaking on?

Please write a short description of your topic(s):

*Please select the partnership meeting(s) you are interested in speaking at:

□ TC 1600 Biotechnology/Chemical/Pharmaceutical Customer Partnership Meeting – Biotechnology and Organic Fields

□ TC 1700 Customer Partnership Meeting – Chemical and Materials Engineering

□ TC 2400 Cyber Security Customer Partnership Meeting

□ TC 2600 Customer Partnership Meeting - Communications

□ TC 2800 Semiconductor Customer Partnership Meeting - Semiconductors, Electrical and Optical Systems and Components

□ TC 2900 Design Day - Designs

□ TC 3600 Business Methods Customer Partnership Meeting - Electronic Commerce, Licensing and Review

□ TC 3600 & 3700 Customer Partnership Meeting - Transportation, Construction, Agriculture, Mechanical Engineering, Manufacturing and Products

□ Partnering in Patents – in collaboration with all TCs and AIPLA

□ No preference

*Please select which regional offices or venue would be best for you to speak from:

□ Alexandria, Virginia

□ Dallas, Texas

□ Denver, Colorado

□ Detroit, Michigan

□ San Jose, California

□ Virtually via WebEx

Additional Comments:

Thank You

A CPM Specialist will contact you about your speaking interests. For additional questions, comments, or information regarding Customer Partnership Meetings, please email [email protected].

Privacy Act Statement

The Privacy Act of 1974 (P.L. 93-579) requires that you be given certain information in connection with your submission of the attached form related to a patent application or patent. Accordingly, pursuant to the requirements of the Act, please be advised that: (1) the general authority for the collection of this information is 35 U.S.C. 2(b)(2); (2) furnishing of the information solicited is voluntary; and (3) the principal purpose for which the information is used by the U.S. Patent and Trademark Office is to process and/or examine your submission related to a patent application or patent. If you do not furnish the requested information, the U.S. Patent and Trademark Office may not be able to process and/or examine your submission, which may result in termination of proceedings or abandonment of the application or expiration of the patent.

The information provided by you in this form will be subject to the following routine uses:

1. The information on this form will be treated confidentially to the extent allowed under the Freedom of Information Act (5 U.S.C. 552) and the Privacy Act (5 U.S.C 552a). Records from this system of records may be disclosed to the Department of Justice to determine whether disclosure of these records is required by the Freedom of Information Act.

2. A record from this system of records may be disclosed, as a routine use, in the course of presenting evidence to a court, magistrate, or administrative tribunal, including disclosures to opposing counsel in the course of settlement negotiations.

3. A record in this system of records may be disclosed, as a routine use, to a Member of Congress submitting a request involving an individual, to whom the record pertains, when the individual has requested assistance from the Member with respect to the subject matter of the record.

4. A record in this system of records may be disclosed, as a routine use, to a contractor of the Agency having need for the information in order to perform a contract. 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).

5. A record related to an International Application filed under the Patent Cooperation Treaty in this system of records may be disclosed, as a routine use, to the International Bureau of the World Intellectual Property Organization, pursuant to the Patent Cooperation Treaty.

6. A record in this system of records may be disclosed, as a routine use, to another federal agency for purposes of National Security review (35 U.S.C. 181) and for review pursuant to the Atomic Energy Act (42 U.S.C. 218(c)).

7. A record from this system of records may be disclosed, as a routine use, to the Administrator, General Services, or his/her designee, during an inspection of records conducted by GSA as part of that agency’s responsibility to recommend improvements in records management practices and programs, under authority of 44 U.S.C. 2904 and 2906. Such disclosure shall be made in accordance with the GSA regulations governing inspection of records for this purpose, and any other relevant (i.e., GSA or Commerce) directive. Such disclosure shall not be used to make determinations about individuals.

8. A record from this system of records may be disclosed, as a routine use, to the public after either publication of the application pursuant to 35 U.S.C. 122(b) or issuance of a patent pursuant to 35 U.S.C. 151. Further, a record may be disclosed, subject to the limitations of 37 CFR 1.14, as a routine use, to the public if the record was filed in an application which became abandoned or in which the proceedings were terminated and which application is referenced by either a published application, an application open to public inspection or an issued patent.

9. A record from this system of records may be disclosed, as a routine use, to a Federal, State, or local law enforcement agency, if the USPTO becomes aware of a violation or potential violation of law or regulation.

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PRA Statement

The United States Patent and Trademark Office (USPTO) is conducting this poll to gather information from stakeholders interested in speaking at a customer partnership event. This poll is strictly voluntary, includes 5 questions and should take approximately 3 minutes to complete. This information collection contains requirements subject to the Paperwork Reduction Act (PRA). Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be subject to penalty for failure to comply with, a collection of information subject to the requirements of the PRA, unless that collection of information displays a currently valid OMB control number.

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