Provisional Application for Patent Cover Sheet

I nstructions for Provisional Application for Patent Cover Sheet

U.S. Patent and Trademark Office; U.S. DEPARTMENT OF COMMERCE

updated May 12, 2008

Contents PDF Form-Fillable Instructions Detailed Instructions for Fields Applicant Information Correspondance Information Application Information Representative Information Domestic Benefit/National Stage Information Foreign Priority Information Assignee Information Signature Country Code Table WIPO ST.3 Table State/Province List Active Military Descriptions Table _________________________________ 1. Form-Fillable Instructions Overview USPTO fill-in PDF forms use the features provided with Adobe Acrobat products. There is some validation of the information you enter but you are still responsible for entering all required information (instructions may require some information to be handwritten on the form). Software Requirements To view, complete and print USPTO fill-in PDF forms you will need the free Adobe Acrobat Reader software installed on your computer. Version 7.0.8, 7.0.9, 8.1.1, or 8.1.2 of Adobe Reader is recommended. Opening the Form Your web browser may be configured with an Adobe Reader plug-in to automatically open the file within your browser's window upon download. To download the file directly to disk, right click the form title link then select "Save Target/Link As..." from the menu. Use Adobe Reader to open the file.

Completing the Form When positioning the cursor on a fill-in area or element, the cursor will change appearance. The I-beam pointer allows you to type text. The hand pointer allows you to select a check box or radio button. Enter the appropriate data in each box or field. To move from one field to the next, press the Tab key. You can also use your cursor to move from field to field. Place your cursor in the field you want to fill in, then left-click. Some fields limit the maximum number of characters you can enter and may automatically advance to the next field. For additional help with fill-in forms, see the Adobe Reader's online help information. Tips: Use the latest version of Adobe Reader in order to ensure the form’s full functionality This fill-in form permits the entered data to be automatically loaded into the Office’s electronic systems, such as PALM when electronically submitted. Printing the form, scanning it to create a PDF and submitting the scan of the printed form will require Office Personnel to key in the information by hand. Save a copy of your work to avoid loss. The USPTO is only accepting certain types of applications electronically. Visit www.uspto.gov for more details

2. Detailed Form Instructions by Field

Inventor Information:

Inventor	One who contributes to the conception of an invention. The patent law of the United States of America requires that the applicant in a patent application must be the inventor.
Given Name	Enter the first or given name of the inventor. If the inventor has only one name, enter a period in this field.
Middle name	Enter any middle name of the inventor. (Optional)
Family Name	Enter the last or family name of the inventor.
City	Enter the city of the inventor’s residence. REQUIRED if the inventor is a U.S. resident or Non-U.S. resident.
State	If the inventor’s address is in the United States or in a U.S. territory, enter the state of the inventor’s residence. See State/Province List for choices.
Country	Enter the country of the inventor’s residence. REQUIRED. See Country Code Table for complete listing, along with abbreviation.
Additional Inventors	Joint inventors must apply for a patent jointly. Select the Add button to add additional inventor information.
Country	Enter the country of the representative’s address. See Country Code Table for complete listing, along with abbreviation.

Application Information:

Title of the Invention

The title of the invention may have up to 500 characters and it must be as short and specific as possible. The approved characters include: A-Z,0-9,standard keyboard characters plus ƒ,…,Œ,™,œ,Ÿ,¡,¢,£,¤,¥,§,©,ª,«,¬,®,°,±,²,³,µ,¹,º, »,¼,½,¾,¿, À,Á,Â,Ã,Ä,Å,Æ,Ç,È,É,Ê,Ë,Ì,Í,Î,Ï,Ñ,Ò,Ó,Ô,Õ,Ö,Ø,Ù,Ú,Û,Ü,Ý, ß,à,á,â,ã,ä,å,æ,ç,è,é,ê,ë,ì,í,î,ï,ñ,ò,ó,ô,õ,ö,÷,ø,ù,ú,û,ü,ý,ÿ, NOTE: Please see the EFS-Web FAQ’s regarding using special characters in Title of Invention and in all the Named fields for Inventors. http://www.uspto.gov/main/faq/p320efsw064.htm.

Attorney Docket Number

This field is optional. It may be used to enter an internal reference number associated with this submission. This field is limited to 25 characters.

Correspondence Information:

Direct all correspondence to	Select the radio button next to "The address corresponding to Customer Number" or "Firm or Individual Name" to indicate where correspondence should be directed. When filing an application, a correspondence address must be set forth in either an application data sheet (§ 1.76), or elsewhere, in a clearly identifiable manner, in any paper submitted with an application filing. If no correspondence address is specified, the Office may treat the mailing address of the first named inventor (if provided, see §§ 1.76(b)(1) and 1.63(c)(2)) as the correspondence address. The Office will direct all notices, official letters, and other communications relating to the application to the correspondence address. The Office will not engage in double correspondence with an applicant and a registered attorney or agent, or with more than one registered attorney or agent except as deemed necessary by the Director. If more than one correspondence address is specified, the Office will establish one as the correspondence address. For the party to whom correspondence is to be addressed, a daytime telephone number should be supplied in a clearly identifiable manner and may be changed by any party who may change the correspondence address.
Customer Number	Enter the customer number associated with the address where correspondence in this application should be sent. A number assigned by the Office that is used to simplify the submission of an address change, to appoint a practitioner, or to designate the fee address for a patent. Customer numbers are primarily used by attorneys and law firms, and must be requested using the "Request for Customer Number" form (PTO/SB/125). (Previously referred to as "payor number") -
Firm or Individual Name-1	Enter the name for the correspondence address.
Firm or Individual Name-2	Enter any additional name information for the address.
Address-1	Enter the first line of the correspondence address.
Address-2	Enter the second line of the correspondence address.
City	Enter the city for the correspondence address.
State / Province	If the correspondence address is located in the United States or in a U.S. territory, enter the state for the correspondence address. REQUIRED for a correspondence address that is in the United States or U.S. territories. See State/Province List for choices.
Country	Enter the country of the correspondence address. See Country Code Table for complete listing, along with abbreviation.
Postal Code	Enter the 5 - 9 digit postal code for the correspondence address. Entry of a postal code for foreign countries is optional.

U.S. Government Agency:

U.S. Government

Select whether invention was made by an agency of the United States Government or under a contract with an agency of the United States Government. If yes, provide the Government contract number.

Entity Status:

Entity Status

For purposes of small entity determination per MPEP 509.02 – small entity means an independent inventor, a small business concern, or a nonprofit organization eligible for reduced patent fees.

Signature:

Signature	This signature is an electronic legal signature. The individual named MUST add a signature. Electronic signature should be in the format /###/ where # is alpha-numeric, space or punctuation (but not / or ?), it cannot just have space or punctuations. Example: "/John Doe/". For more information see 37 CFR 1.4(d).
Date	Enter the date that the submission is being signed. Or, select the date from the drop-down menu, which converts into a calendar. The date format should be in the form YYYY-MM-DD.
First Name	Type the first name of the filer.
Last Name	Type the last name of the filer
Registration Number	Please enter a Registration Number if you are a patent practitioner.

3. Country Code Table

COUNTRY	CODE
AFGHANISTAN	AF
ALBANIA	AL
ALGERIA	DZ
ANDORRA	AD
ANGOLA	AO
ANGUILLA	AI
ANTARCTICA	AQ
ANTIGUA AND BARBUDA	AG
ARGENTINA	AR
ARMENIA	AM
ARUBA	AW
AUSTRALIA	AU
AUSTRIA	AT
AZERBAIJAN	AZ
BAHAMAS	BS
BAHRAIN	BH
BANGLADESH	BD
BARBADOS	BB
BELARUS	BY
BELGIUM	BE
BELIZE	BZ
BENIN	BJ
BERMUDA	BM
BHUTAN	BT
BOLIVIA	BO
BOSNIA AND HERZEGOVINA	BA
BOTSWANA	BW
BOUVET ISLAND	BV
BRAZIL	BR
BRITISH INDIAN OCEAN TERRITORY	IO
BRUNEI DARUSSALAM	BN
BULGARIA	BG
BURKINA FASO	BF
BURUNDI	BI
CAMBODIA	KH
CAMEROON	CM
CANADA	CA
CANTON AND ENDERBURY ISLANDS	CT
CAPE VERDE	CV
CAYMAN ISLANDS	KY
CENTRAL AFRICAN REPUBLIC	CF
CHAD	TD
CHILE	CL
CHINA	CN
CHRISTMAS ISLAND	CX
COCOS (KEELING) ISLANDS	CC
COLOMBIA	CO
COMOROS	KM
CONGO	CG
CONGO, THE DEMOCRATIC REPUBLIC OF THE	CD
COOK ISLANDS	CK
COSTA RICA	CR
COTE D'IVOIRE	CI
CROATIA	HR
CUBA	CU
CYPRUS	CY
CZECH REPUBLIC	CZ
CZECHOSLOVAKIA	CS
DENMARK	DK
DJIBOUTI	DJ
DOMINICA	DM
DOMINICAN REPUBLIC	DO
DRONNING MAUD LAND	NQ
EAST TIMOR	TP
ECUADOR	EC
EGYPT	EG
EL SALVADOR	SV
EQUATORIAL GUINEA	GQ
ERITREA	ER
ESTONIA	EE
ETHIOPIA	ET
FALKLAND ISLANDS (MALVINAS)	FK
FAROE ISLANDS	FO
FIJI	FJ
FINLAND	FI
FRANCE	FR
FRENCH GUIANA	GF
FRENCH POLYNESIA	PF
FRENCH SOUTHERN AND ANTARCTIC TERRITORIES	FQ
FRENCH SOUTHERN TERRITORIES	TF
GABON	GA
GAMBIA	GM
GEORGIA	GE
GERMAN DEMOCRATIC REPUBLIC	DD
GERMANY	DE
GHANA	GH
GIBRALTAR	GI
GREECE	GR
GREENLAND	GL
GRENADA	GD
GUADELOUPE	GP
GUATEMALA	GT
GUINEA	GN
GUINEA-BISSAU	GW
GUYANA	GY
HAITI	HT
HEARD ISLAND AND MCDONALD ISLANDS	HM
HOLY SEE (VATICAN CITY STATE)	VA
HONDURAS	HN
HONG KONG	HK
HUNGARY	HU
ICELAND	IS
INDIA	IN
INDONESIA	ID
IRAN, ISLAMIC REPUBLIC OF	IR
IRAQ	IQ
IRELAND	IE
ISRAEL	IL
ITALY	IT
JAMAICA	JM
JAPAN	JP
JORDAN	JO
KAZAKSTAN	KZ
KENYA	KE
KIRIBATI	KI
KOREA, DEMOCRATIC PEOPLE'S REPUBLIC OF	KP
KOREA, REPUBLIC OF	KR
KUWAIT	KW
KYRGYZSTAN	KG
LAO PEOPLE'S DEMOCRATIC REPUBLIC	LA
LATVIA	LV
LEBANON	LB
LESOTHO	LS
LIBERIA	LR
LIBYAN ARAB JAMAHIRIYA	LY
LIECHTENSTEIN	LI
LITHUANIA	LT
LUXEMBOURG	LU
MACAU	MO
MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF	MK
MADAGASCAR	MG
MALAWI	MW
MALAYSIA	MY
MALDIVES	MV
MALI	ML
MALTA	MT
MARSHALL ISLANDS	MH
MARTINIQUE	MQ
MAURITANIA	MR
MAURITIUS	MU
MAYOTTE	YT
MEXICO	MX
MIRCRONESIA, FEDERATED STATES OF	FM
MOLDOVA, REPUBLIC OF	MD
MONACO	MC
MONGOLIA	MN
MONTSERRAT	MS
MOROCCO	MA
MOZAMBIQUE	MZ
MYANMAR	MM
NAMIBIA	NA
NAURU	NR
NEPAL	NP
NETHERLANDS	NL
NETHERLANDS ANTILLES	AN
NEUTRAL ZONE	NT
NEW CALEDONIA	NC
NEW ZEALAND	NZ
NICARAGUA	NI
NIGER	NE
NIGERIA	NG
NIUE	NU
NORFOLK ISLAND	NF
NORWAY	NO
NOT PROVIDED	XP
OMAN	OM
PACIFIC ISLANDS (TRUST TERRITORY)	PC
PAKISTAN	PK
PALAU	PW
PANAMA	PA
PANAMA CANAL ZONE	PZ
PAPUA NEW GUINEA	PG
PARACEL ISLANDS	QP
PARAGUAY	PY
PERU	PE
PHILIPPINES	PH
PITCAIRN	PN
POLAND	PL
PORTUGAL	PT
QATAR	QA
REUNION	RE
ROMANIA	RO
RUSSIAN FEDERATION	RU
RWANDA	RW
SAINT HELENA	SH
SAINT KITTS AND NEVIS	KN
SAINT LUCIA	LC
SAINT PIERRE AND MIQUELON	PM
SAINT VINCENT AND THE GRENADINES	VC
SAMOA	WS
SAN MARINO	SM
SAO TOME AND PRINCIPE	ST
SAUDI ARABIA	SA
SENEGAL	SN
SEYCHELLES	SC
SIERRA LEONE	SL
SINGAPORE	SG
SLOVAKIA	SK
SLOVENIA	SI
SOLOMON ISLANDS	SB
SOMALIA	SO
SOUTH AFRICA	ZA
SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS	GS
SPAIN	ES
SRI LANKA	LK
STATELESS	ZZ
SUDAN	SD
SURINAME	SR
SVALBARD AND JAN MAYEN	SJ
SWAZILAND	SZ
SWEDEN	SE
SWITZERLAND	CH
SYRIAN ARAB REPUBLIC	SY
TAIWAN	TW
TAJIKISTAN	TJ
TANZANIA, UNITED REPUBLIC OF	TZ
THAILAND	TH
TOGO	TG
TOKELAU	TK
TONGA	TO
TRINIDAD AND TOBAGO	TT
TUNISIA	TN
TURKEY	TR
TURKMENISTAN	TM
TURKS AND CAICOS ISLANDS	TC
TUVALU	TV
UGANDA	UG
UKRAINE	UA
UNION OF SOVIET SOCIALIST REPUBLICS	SU
UNITED ARAB EMIRATES	AE
UNITED KINGDOM	GB
UNITED STATES	US
URUGUAY	UY
UZBEKISTAN	UZ
VANUATU	VU
VENEZUELA	VE
VIET NAM	VN
VIET-NAM, DEMOCRATIC REPUBLIC OF	VD
VIRGIN ISLANDS, BRITISH	VG
WALLIS AND FUTUNA	WF
WESTERN SAHARA	EH
YEMEN	YE
YEMEN, DEMOCRATIC	YD
YUGOSLAVIA	YU
ZAMBIA	ZM
ZIMBABWE	ZW

4. WIPO ST.3 Table

COUNTRY	CODE
ANDORRA	AD
UNITED ARAB EMIRATES	AE
AFGHANISTAN	AF
ALGERIA	DZ
ANTIGUA AND BARBUDA	AG
ANGUILLA	AI
ARMENIA	AM
ALBANIA	AL
NETHERLANDS ANTILLES	AN
ANGOLA	AO
AFRICAN REGIONAL INDUSTRIAL PROPERTY ORGANIZATION (ARIPO)	AP
ARGENTINA	AR
AUSTRALIA	AU
ARUBA	AW
AZERBAIJAN	AZ
BANGLADESH	BD
BOSNIA AND HERZEGOVINA	BA
BAHRAIN	BH
BARBADOS	BB
BELGIUM	BE
BULGARIA	BG
BHUTAN	BT
BURUNDI	BI
BERMUDA	BM
BRUNEI DARUSSALAM	BN
BOLIVIA	BO
BRAZIL	BR
BAHAMAS	BS
BOTSWANA	BW
MYANMAR	MM
BOUVET ISLAND	BV
BENELUX TRADEMARK OFFICE (BBDM) AND BENELUX DESIGNS OFFICE (BBDM)	BX
BELARUS	BY
BELIZE	BZ
CANADA	CA
DEMOCRATIC REPUBLIC OF THE CONGO	CD
CHILE	CL
CONGO	CG
SWITZERLAND	CH
COTE D'IVOIRE	CI
COOK ISLANDS	CK
SRI LANKA	LK
COLOMBIA	CO
COSTA RICA	CR
CUBA	CU
HOLY SEE	VA
CAPE VERDE	CV
CYPRUS	CY
CZECH REPUBLIC	CZ
BENIN	BJ
DJIBOUTI	DJ
DENMARK	DK
DOMINICA	DM
DOMINICAN REPUBLIC	DO
GERMANY	DE
ETHIOPIA	ET
EURASIAN PATENT ORGANIZATION (EAPO)	EA
ECUADOR	EC
ESTONIA	EE
WESTERN SAHARA	EH
IRELAND	IE
EUROPEAN (EU) OFFICE FOR HARMONIZATION IN THE INTERNAL MARKET (OHIM)	EM
EUROPEAN PATENT OFFICE (EPO)	EP
ERITREA	ER
SPAIN	ES
EGYPT	EG
FIJI	FJ
FALKLAND ISLANDS (MALVINAS)	FK
LIECHTENSTEIN	LI
FAROE ISLANDS	FO
FRANCE	FR
GABON	GA
UNITED KINGDOM	GB
PATENT OFFICE OF THE COOPERATION COUNCIL FOR THE ARAB STATES OF THE GULF (GCC)	GC
GRENADA	GD
GAMBIA	GM
GEORGIA	GE
GHANA	GH
GUINEA	GN
GIBRALTAR	GI
GREENLAND	GL
EQUATORIAL GUINEA	GQ
GREECE	GR
SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS	GS
GUATEMALA	GT
GUINEA-BISSAU	GW
GUYANA	GY
HAITI	HT
THE HONG KONG SPECIAL ADMINISTRATIVE REGION OF THE PEOPLE'S REPUBLIC OF CHINA	HK
HONDURAS	HN
CROATIA	HR
HUNGARY	HU
INTERNATIONAL BUREAU OF THE WORLD INTELLECTUAL PROPERTY ORGANIZATION (WIPO)	IB
INDONESIA	ID
ISRAEL	IL
INDIA	IN
IRAQ	IQ
IRAN, ISLAMIC REPUBLIC OF	IR
ICELAND	IS
ITALY	IT
JAPAN	JP
JAMAICA	JM
JORDAN	JO
CAMEROON	CM
KENYA	KE
KYRGYZSTAN	KG
KIRIBATI	KI
COMOROS	KM
DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA	KP
SAINT KITTS AND NEVIS	KN
REPUBLIC OF KOREA	KR
KUWAIT	KW
CAYMAN ISLANDS	KY
KAZAKHSTAN	KZ
LAOS	LA
LEBANON	LB
SAINT LUCIA	LC
LIBERIA	LR
LESOTHO	LS
LITHUANIA	LT
LUXEMBOURG	LU
LATVIA	LV
LIBYA	LY
MOROCCO	MA
MONACO	MC
MADAGASCAR	MG
REPUBLIC OF MOLDOVA	MD
MALI	ML
THE FORMER YUGOSLAV REPUBLIC OF MACEDONIA	MK
MALTA	MT
MONGOLIA	MN
MACAU	MO
NORTHERN MARIANA ISLANDS	MP
MAURITIUS	MU
MONTSERRAT	MS
MAURITANIA	MR
OMAN	OM
MALDIVES	MV
MALAWI	MW
MEXICO	MX
MALAYSIA	MY
MOZAMBIQUE	MZ
NICARAGUA	NI
NAMIBIA	NA
NIGER	NE
NETHERLANDS	NL
NORWAY	NO
NEPAL	NP
NAURU	NR
NEW ZEALAND	NZ
AFRICAN INTELLECTUAL PROPERTY ORGANIZATION (OAPI)	OA
AUSTRIA	AT
PERU	PE
PARAGUAY	PY
PHILIPPINES	PH
PAKISTAN	PK
PANAMA	PA
POLAND	PL
PAPUA NEW GUINEA	PG
PORTUGAL	PT
PALAU	PW
QATAR	QA
CHINA	CN
ROMANIA	RO
RUSSIAN FEDERATION	RU
RWANDA	RW
SAUDI ARABIA	SA
SOLOMON ISLANDS	SB
SEYCHELLES	SC
SUDAN	SD
FINLAND	FI
SINGAPORE	SG
SAINT HELENA	SH
SLOVENIA	SI
SLOVAKIA	SK
EL SALVADOR	SV
SAN MARINO	SM
SENEGAL	SN
SOMALIA	SO
SYRIA	SY
SURINAME	SR
SAO TOME AND PRINCIPE	ST
SWEDEN	SE
SWAZILAND	SZ
UNITED REPUBLIC OF TANZANIA	TZ
TURKS AND CAICOS ISLANDS	TC
TRINIDAD AND TOBAGO	TT
THAILAND	TH
TONGA	TO
TAJIKISTAN	TJ
TURKMENISTAN	TM
TUNISIA	TN
TOGO	TG
EAST TIMOR	TP
TURKEY	TR
CHAD	TD
TUVALU	TV
TAIWAN	TW
UKRAINE	UA
UGANDA	UG
UNITED STATES OF AMERICA	US
BURKINA FASO	BF
URUGUAY	UY
UZBEKISTAN	UZ
SAINT VINCENT AND THE GRENADINES	VC
VENEZUELA	VE
VIRGIN ISLANDS, BRITISH	VG
VIET NAM	VN
VANUATU	VU
SIERRA LEONE	SL
NIGERIA	NG
WORLD INTELLECTUAL PROPERTY ORGANIZATION (WIPO) (INTERNATIONAL BUREAU OF)	WO
SAMOA	WS
YUGOSLAVIA	YU
SOUTH AFRICA	ZA
ZAMBIA	ZM
CENTRAL AFRICAN REPUBLIC	CF
CAMBODIA	KH
ZIMBABWE	ZW
YEMEN	YE
EUROPEAN (EU) COMMUNITY PLANT VARIETY OFFICE (CPVO)	QZ

5. State/Province List

U.S. State / U.S. territories / Canadian Provinces	Code
ALABAMA	AL
ALASKA	AK
ALBERTA	AB
AMERICAN SAMOA	AS
ARIZONA	AZ
ARKANSAS	AR
Armed Forces in Americas excluding Canada	AA
Armed Forces in Europe, the Middle East, Africa, and Canada	AE
Armed Forces in the Pacific	AP
BAKER ISLAND	81
BRITISH COLUMBIA	BC
CALIFORNIA	CA
CHANNEL ISLANDS	CHA
COLORADO	CO
CONNECTICUT	CT
DELAWARE	DE
DISTRICT OF COLUMBIA	DC
FLORIDA	FL
GEORGIA	GA
GUAM	GU
HAWAII	HI
HOWLAND ISLAND	84
IDAHO	ID
ILLINOIS	IL
INDIANA	IN
IOWA	IA
JARVIS ISLAND	86
JOHNSTON ATOLL	67
KANSAS	KS
KENTUCKY	KY
KINGMAN REEF	89
LOUISIANA	LA
MAINE	ME
MANITOBA	MB
MARYLAND	MD
MASSACHUSETTS	MA
MICHIGAN	MI
MIDWAY ISLANDS	71
MINNESOTA	MN
MISSISSIPPI	MS
MISSOURI	MO
MONTANA	MT
NAVASSA ISLAND	76
NEBRASKA	NE
NEVADA	NV
NEW BRUNSWICK	NB
NEW HAMPSHIRE	NH
NEW JERSEY	NJ
NEW MEXICO	NM
NEW YORK	NY
NEWFOUNDLAND	NF
NORTH CAROLINA	NC
NORTH DAKOTA	ND
NORTHWEST TERRITORIES	NT
NOVA SCOTIA	NS
NUNAVUT	NU
OHIO	OH
OKLAHOMA	OK
ONTARIO	ON
OREGON	OR
PALMYRA ATOLL	95
PENNSYLVANIA	PA
PRINCE EDWARD ISLAND	PE
PUERTO RICO	PR
QUEBEC	QC
RHODE ISLAND	RI
SASKATCHEWAN	SK
SOUTH CAROLINA	SC
SOUTH DAKOTA	SD
TENNESSEE	TN
TEXAS	TX
UNITED STATES MINOR OUTLYING ISLANDS	UM
UTAH	UT
VERMONT	VT
VIRGIN ISLANDS, U.S.	VI
VIRGINIA	VA
WAKE ISLAND	79
WASHINGTON	WA
WEST VIRGINIA	WV
WISCONSIN	WI
WYOMING	WY
YUKON TERRITORY	YT

6. Active Military Descriptions Table

AE	The inventor is serving in Europe or Africa
AP	The inventor is serving in the Pacific
AA	The inventor is serving in the Americas excluding Canada