2018 VILT Interest Form

OMB Control No.: 0651-0080

Expiration Date: 8/31/2018

Final Interest Form:

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The form below may be used to request participation in the Virtual Instructor-Led Training (VILT) Program. Please fill in the information desired below and click on the “submit” button.

Requests to participate in VILT are granted depending upon resources, training time available, and the intended target audience for each course.

Enter Requesting Information

*Items are mandatory

*Requested Course:__drop down menu___________

*First Name:_________________________________

*Last Name:_________________________________

*Company/Organization:_______________________

*Correspondence Address:

Street Address:_______________________

City:________________________________

State/Province:_______________________

Postal/Zip Code:______________________

Country: ____________________________

*E-mail Address:____________________________

*Telephone Number:_________________________

*Years of Patent Related Experience: (selection: 0-1, 1-3, 3-5, 5+)

*Are you registered to practice law in patent matters before the USPTO? y/n

*Registration number: ___(only fillable if Yes is selected)

*Are you admitted to a state bar in the United States? y/n

*State:___ (only fillable if Yes is selected)

*Bar number:___ (only fillable if Yes is selected)

*Are you an inventor and have you filed, or plan on filing, a patent application? y/n

*Do you plan on filing an application as a Pro Se inventor? y/n

If you meet the requirements for the course applied for but are not selected do you want to be notified when the same or similar course becomes available? y/n

Requests to participate in VILT are granted depending upon resources, training time available, and the intended target audience for each course.

If you have any feedback, questions or comments regarding VILT, please email us at [email protected].

Privacy Act Statement

The authority for the collection of this information is 5 U.S.C. § 301, 35 U.S.C. § 2, and E.O. 12862. The information you provide will be used to verify your identity and administer participation in VILT courses. The information you provide is protected from disclosure to third parties in accordance with the Privacy Act. However, routine uses of this information may include disclosure to the following: Congressional offices; Federal, state, local or foreign agencies; a court, magistrate or administrative tribunal; law enforcement; agents or contractors; the Department of Justice; the National Archives and Records Administration; and agency customers in the course of distributing patent and trademark business information. Disclosure of the information by you is voluntary; however, failure to provide any part of the requested information may result in our inability to enroll you in VILT courses. The applicable Privacy Act System of Records Notice for this information request is PAT/TM–23, User Access for Web Portals and Information Requests, available at https://www.uspto.gov/uspto-systems-records-notices.

PRA Statement of Burden

The United States Patent and Trademark Office (USPTO) is using this report form to gauge interest with the VILT Program. This report is strictly voluntary, includes 20 questions and should take around 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.