Form PTO-2224 Form to collect data from public searchers

PTO-2224 (7/2006)
Approved for use through XX/XX/XXXX. OMB 0651-0041
U.S. Patent and Trademark Office; U.S. DEPARTMENT OF COMMERCE
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.

FORM TO COLLECT DATA FROM PUBLIC SEARCHERS

In order for the Office of Security to issue a SMART card, it is essential that each intended user
provide the information, as requested below.
Once the appropriate information is received and final processing completed, you will be notified
and provided instructions for receiving your Smart card.
Should you have any questions or require additional assistance, please do not hesitate to contact
the Security Service Center at (571) 272-8000.

Last Name:

First Name:

Date of Birth:

Middle Initial:

Last five digits of SSN:____________________________
(Format: 09-16-1958)

Place of Birth:
(Indicate City and two-letter code for State; if not in the U.S. then indicate Country)

Home #:
Work #.:

Signature:

Today’s Date:
PRA Statement

This collection of information is authorized by 5 U.S.C. § 301, 35 U.S.C. § 2, 41 CFR Part 102-81, and E.O. 9397 and is used by the
public to apply for (and by the USPTO to issue) security identification badges for public search room users. The information on this
form will be treated confidentially to the extent allowed under the Freedom of Information Act (FOIA) and the Privacy Act.
Submission of this information is voluntary; however, if you do not provide this information, you will not be issued a security
identification badge. The USPTO will use this information primarily to issue official identification badges to individuals accessing
USPTO facilities and to maintain a record of all holders of these identification badges, to renew and recover expired badges, and to
identify badges that are lost or stolen. This form is estimated to take 5 minutes to complete, including gathering the necessary
information, preparing the form, and submitting the request to the USPTO Security Office. Any comments on the amount of time
you require to complete this form and/or suggestions for reducing this burden should be sent to the Director of the Security Office,
USPTO, P.O. Box 1450, Alexandria, VA 22313-1450

(See reverse for additional information regarding the SMART card)

SMART card holder responsibilities:
Following is additional information regarding the safeguarding of the SMART card that you will
be issued. By not properly adhering to the information provided below, your card will be
immediately deactivated.

This badge is only issued for use in our Public Search Facility/Area.
I certify that I will only use this badge for search purposes.

1. WEARING/DISPLAYING: As the SMART card will also be considered the USPTO
official identification, the front of the card (photo or type side) must be prominently displayed at
all times. When displaying the card, it will be worn between the neck and waist.
2. SAFEGUARDING: When not wearing the SMART card or the card is not in your physical
custody, it will be secured against loss or theft in the same or similar manner, as you would
protect your purse or wallet against loss or theft.
3. USE: The SMART card will be used for official purposes only and it will not be loaned,
given or otherwise allowed by any other person to use the card for any purpose.
4. REPORTING LOSS OR THEFT: The loss or theft of the SMART card will be reported to
the Office of Security at (571) 272-8000. If the lost or stolen card is subsequently recovered, it
will be promptly returned to the Office of Security.
5. RETURN OF CARD: The SMART card will be immediately returned to the Office of
Security when you are no longer searching, or upon request by the Office of Security.
6. REISSUE SMART CARD: If you have lost your smart card, in order to obtain a
replacement a $15.00 fee will be needed by personal check or money order. Make your checks
or money orders out to Director USPTO.
Privacy Act Statement
The United States Patent and Trademark Office (USPTO) collects this information under authority of 41 CFR
102-74.375(c). The information in this system of records is used to manage users of the public facilities of the
USPTO and may collect: name; addresses; telephone numbers; business firm or other organizations with which
affiliated; user access number; record of use; violations of policies governing use of the facilities; signature of
recipients of user access number; and other information as needed to establish identity.
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 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 non-federal personnel under contract to
the agency; to a court for adjudication and litigation; 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 for personnel research purposes; to National Archives and Records Administration for inspection of
records; and to the Office of Management and Budget for legislative coordination and clearance. Failure to provide
any part of the requested information may result in an inability to obtain a security badge. The applicable Privacy Act
System of Records Notice for this information is COMMERCE/PAT–TM–14, Users of Public Facilities of the Patent
and Trademark Office: Federal Register / Vol. 78, No. 53 / Tuesday, March 19, 2013 / Notices available at https://
www.govinfo.gov/content/pkg/FR-2013-03-19/pdf/2013-06262.pdf