Registration Declaration for Utility Patent Application

National Patent Application Drafting Competition
OMB control # 0690-0031 expires 08/31/2023
Under the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless it displays a valid OMB control number.

REGISTRATION DECLARATION
FOR UTILITY

Team #
Filing Date

PATENT APPLICATION
DRAFTING COMPETITION

First Coach/Contact
email and phone
Second coach (if any)
email and phone

(Name of the team or school, and name of the invention)

As a below named student team member, I hereby declare that:
•
•
•
•
•
•
•

The attached application was created and written by the students listed below.
I am/was enrolled at the institution during the academic year.
If a registered patent practitioner, my patent registration number was issued
after the date listed in the competition rules.
I have not been admitted or licensed to practice law in any jurisdiction.
I am not a current employee of the USPTO.
I will follow all competition rules.

I hereby acknowledge that any willful false statement made in this declaration is
punishable by removal from the National Patent Application Drafting Competition.

Direct all
correspondence to:
Name of Coach
Email Address

City

State

Country

Telephone

[Page 1 of 3]
If you need assistance in completing the form, email [email protected].

National Patent Application Drafting Competition
OMB control # 0690-0031 expires 08/31/2023
Under the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless it displays a valid OMB control number.

Registration — Utility Patent Application Competition
REMINDERS:
The team members listed below must represent this school at each phase of the Competition,
including but not limited to, search, preparation of the written patent application and appearance(s)
at the regional and national phases of the Competition to give the presentation(s). Should a
student have to individually withdraw from the Competition, the remaining team members may
choose to continue in the Competition (if the team originally comprised three or four competitors) or
withdraw from the Competition.
This form will be separated from the remainder of the application. Within the remainder of this
patent application, teams must identify themselves only by use of the team number given to
them with the invitation, in November, by the organizing committee.
This form must be accompanied by a complete patent application, a completed IDS and a
summary as stated in the rules: https://www.uspto.gov/sites/default/files/documents/PDCRules.pdf
LEGAL NAME OF FIRST STUDENT:

(e.g., Given Name (first and middle if any) and Family Name or Surname)
Student's Signature

Residence: City

Date (Optional)

State

Country

School:
Reg. # if granted:
EMAIL:

PHONE:

All additional students are named on the next page.

[Page 2 of 3]

National Patent Application Drafting Competition
OMB control # 0690-0031 expires 08/31/2023
Under the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless it displays a valid OMB control number.

 ADDITIONAL STUDENT(S)

3

Page _

of

3

Legal Name of Second Student:
(e.g., Given Name (first and middle if any) and Family Name or Surname)

Student’s
Signature
Residence: City

Date (Optional)
State

Country

School
EMAIL:

Reg. # if granted:

PHONE:

Legal Name of Third Student, if any:
(e.g., Given Name (first and middle if any) and Family Name or Surname)

Student’s
Signature

Residence: City

Date (Optional)

State

Country

School
Reg. # if granted:

PHONE:

EMAIL:

Legal Name of Fourth Student, if any:
(e.g., Given Name (first and middle if any) and Family Name or Surname)

Student’s
Signature
Residence: City

Date (Optional)
State

Country

School

Reg. # if granted:

EMAIL:

PHONE:

SUBMIT THIS FORM, ALONG WITH THE COMPLETED APPLICATION, TO: [email protected].
Paperwork Reduction Act Statement
Under the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. This form is estimated to take 20 minutes to complete and submit
to USPTO. Any comments on the amount of time you require to complete this activity and/or suggestions for reducing this burden, should be sent to the Chief Administrative Officer, United States Patent and Trademark
Office, P.O. Box 1450, Alexandria, VA 22313-1450.
Privacy Act Statement
The Privacy Act of 1974 (P.L. 93-579) requires that you be given certain information in connection with your registration to participate in an agency-sponsored activity, event, or program. The information in this system of
records is to account for the electronic collection, maintenance and use of information in connection with Department of Commerce activities, events, and programs. Such activities, events, and programs include, but are not
limited to: Conferences, roundtable discussions, forums, exhibits, summits, and presentations.
The authority for the collection of this information is 5 U.S.C. App.—Inspector General Act of 1978, § 2; 5 U.S.C. App.—
Reorganization Plan of 1970, § 2; 13 U.S.C. § 2; 13 U.S.C. § 131; 15 U.S.C. § 272; 15 U.S.C. § 1151; 15 U.S.C. § 1501; 15 U.S.C. § 1512; 15 U.S.C. § 1516; 15 U.S.C. § 3704b; 16 U.S.C. § 1431; 35 U.S.C. § 2; 42 U.S.C. § 3121 et seq.;
47 U.S.C. § 902; 50 U.S.C. App. § 2401 et seq.; E.O. 11625; 77 FR 49699 (Aug. 16, 1012) . The information in this system of records is used to manage Name, organization affiliation, title, address, email, and telephone number;
credit card information; Web site URL; organization category and description; business function; objectives for matchmaking; sponsorship information; exhibition booth preferences; and special requirements for exhibition
needs; and all other information submitted to participate in an agency-sponsored activity, program, or event. 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: to other registrants to facilitate
company/organization matchmaking, to a Federal, state, local, or foreign agency or other appropriate entity where a record, either alone or in conjunction with other information, indicates a violation or potential violation of