Form PTO-107R Data Sheet - Register of Patent Attorneys and Agents

U.S. PATENT AND TRADEMARK OFFICE

OMB No. 0651‐0012 | Approved through x/xx/xxxx | FORM PTO‐107R

REINSTATEMENT DATA SHEET - REGISTER OF PATENT ATTORNEYS AND AGENTS

You must provide a correspondence/business name, address and telephone number in the boxes below. Government employees must provide the name and address of the department or Government agency in the correspondence/business name, address and telephone number boxes. This will be published in the Government publication Attorneys and Agents Registered to Practice Before the United States Patent and Trademark Office. Also provide your home address and telephone number. Only one correspondence address and telephone number will be published. COMPLETE ALL LINES

LEGAL NAME Last Name First Name Middle Name  Mr.  Ms.

FOR USPTO USE ONLY

REGISTRATION NUMBER

E-MAIL (primary)

E‐MAIL (secondary)

CITIZENSHIP (country)

AGENT: _________________________________ ATTORNEY: ______________________________

DATE OF BIRTH (month, day, year)

PLACE OF BIRTH (City, State, Country)

CORRESPONDENCE/BUSINESS NAME Employer, corporation, law firm, U.S. Government agency. Indicate if student or unemployed

CORRESPONDENCE/ BUSINESS ADDRESS (street, bldg., suite, etc.) This address will be used for official correspondence.

BUSINESS NUMBER

BUSINESS CITY

BUSINESS STATE

BUSINESS COUNTRY

BUSINESS ZIP CODE

HOME ADDRESS

HOME NUMBER

HOME CITY

HOME STATE

HOME COUNTRY

HOME ZIP CODE

REINSTATEMENT:



I am applying for reinstatement as a former government employee (administratively inactive). Enclosed is my application fee set forth in 37 CFR § 1.21(a)(1)(i). Also enclosed is the Undertaking form.



I am applying for reinstatement for a change from inactive to active status.



I am applying for reinstatement after discipline. Enclosed is my application fee set forth in 37 CFR § 1.21(a)(10). If you are required to take the Registration Exam, please use Form PTO-158.



I am applying for reinstatement after administrative suspension.  Enclosed is my reinstatement fee and delinquency fee set forth in 37 CFR § 1.21(a)(9).

Registration Status:  ATTORNEY  AGENT If you are an attorney, please list all States of the United States in which you are a member in good standing of the bar of the highest court of the State: ____________________________________________________

 YES

 NO

In the last five (5) years, have you been suspended or disbarred from practice on ethical grounds by any duly constituted authority of a State of the United States, or in the case of a practitioner who resides in a foreign country or is registered under 37 CFR § 11.6(c) by any duly constituted authority of the country in which the practitioner resides? If YES, please attach a statement explaining when, where and the grounds for the disbarment or suspension.

 YES

 NO

In the last five (5) years, have you been convicted of a felony or misdemeanor (other than a traffic violation) by any federal, State or other law enforcement authority? If YES, please attach a statement giving the date, charge, and place of the offense and an explanation of the facts and circumstances leading to the conviction.

 YES

 NO

Are you an employee of the United States Government? PLEASE NOTE: U.S. Government employees are not available to accept private clients or to represent clients other than their agency before the United States Patent and Trademark Office. 18 U.S.C. § 205; 37 CFR §§ 11.10(d) and (e).

 YES

 NO

Are you a former patent examiner of the United States Patent and Trademark Office?

I certify that each and every statement or representation in this Data Sheet is true and accurate (a willfully false certification is a criminal offense and is punishable by law (18 U.S.C. § 1001)).

Signature of Applicant

Date

Page 0 of 3	OMB No. 0651‐0012 | Approved for use through xx/xx/xxxx | FORM PTO‐107R
PRA Act Statement A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with an information collection subject to the requirements of the Paperwork Reduction Act of 1995, unless the information collection has a currently valid OMB Control Number. The OMB Control Number for this information collection is 0651-0012. Public burden for this form is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information collection. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden to the Chief Administrative Officer, United States Patent and Trademark Office, P.O. Box 1450, Alexandria, VA 22313-1450 or email [email protected].
Privacy Act Statement The United States Patent and Trademark Office (USPTO) collects this information under authority of 5 CFR 339.205. The information in this system of records is used to manage biographical information, personal and professional qualifications, character and fitness report, investigations of an applicant’s suitability or eligibility for registration to practice before the USPTO, undertakings of former patent examiners, current address, and status information. 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: Routine uses will include publishing and disseminating a public roster including an address of record, law firm or company affiliation, telephone number, and registration number of the active registered individuals on the USPTO Web site, to law enforcement and investigation in the event that the system of records indicates a violation or potential violation of law; to a Federal, state, local, or international agency, in response to its request; to an agency, organization, or individual for the purpose of performing audit or oversight operations as authorized by law to contractors and their agents, grantees, experts, consultants, and others performing or working on a contract, service, grant, cooperative agreement, or other work assignment for the U.S. Patent and Trademark Office, when necessary to accomplish an agency function related to this system of records; to the Department of Justice for Freedom of Information Act (FOIA) assistance; to members of congress working on behalf of an individual; to the Office of Personnel Management (OPM) for personnel research purposes; to National Archives and Records Administration for inspection of records. Failure to provide any part of the requested information may result in an inability to process requests for access and information. The applicable Privacy Act System of Records Notice for this information is COMMERCE/PAT–TM–1 Attorneys and Agents Registered to Practice Before the Office available at Federal Register /Vol. 78, No. 53 /Tuesday, March 19, 2013 /Notices https://www.federalregister.gov/documents/2013/03/19/2013-06254/privacy-act-of-1974-system-of-records