PTO 158 LS Application for Limited Recognition in USPTO Law School

OED PRIVACY ACT ADVISORY STATEMENT

The Privacy Act of 1974 (P.L. 93-579) requires that you be given certain information in connection with the request for information solicited on attached form PTO-158LS. Accordingly, pursuant to the requirements of the Act, please be advised that (i) the authority for the collection of this data is 35 U.S. C. §§1 and 2(b)(2)(D), (ii) furnishing of the information solicited is voluntary, and (iii) the principal purpose for which the data will be used is to maintain current information relating to your eligibility and fitness for registration to practice before the United States Patent and Trademark Office in patent cases. If you do not furnish the requested information, you will not be admitted to the registration examination or registered to practice before the United States Patent and Trademark Office.

The information provided by you in these forms will be subject to the following routine uses:

(1) 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; registration status is disseminated upon inquiry; and information may be published on the USPTO Web site or otherwise disclosed to solicit information regarding an applicant's suitability and eligibility for registration to practice before the USPTO.

(2) Routine uses will include disclosure for law enforcement purposes to the appropriate agency or other authority, whether federal, state, local, foreign, international or tribal, charged with the responsibility of enforcing, investigating, or prosecuting a violation of any law, rule, regulation, or order in any case in which there is an indication of a violation or potential violation of law (civil, criminal, or regulatory in nature).

(3) Routine uses will include disclosure to an agency, organization, or individual for the purpose of performing audit or oversight operations as authorized by law, but only such information as is necessary and relevant to such audit or oversight function.

(4) Routine uses will include disclosure 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. Individuals provided information under this routine use are subject to the same Privacy Act requirements and limitations on disclosure as are applicable to the U.S. Patent and Trademark Office employees.

(5) Routine uses will include the Prefatory Statement of General Routine Uses Nos. 1-5 and 8-13, as found at 46 FR 63501-63502 (December 31, 1981):

1. In the event that a system or records maintained by the Department to carry out its functions indicates a violation or potential violation of law or contract, whether civil, criminal or regulatory in nature, and whether arising by general statute or particular program statute or contract, or rule, regulation, or order issued pursuant thereto, or the necessity to protect an interest of the Department, the relevant records in the system of records may be referred, as a routine use, to the appropriate agency, whether Federal, state, local or foreign, charged with the responsibility of investigating or prosecuting such violation or charged with enforcing or implementing the statute or contract, or rule, regulation or order issued pursuant thereto, or protecting the interest of the Department.

2. A record from this system of records may be disclosed, as a routine use, to a Federal, state or local agency maintaining civil, criminal or other relevant enforcement information or other pertinent information, such as current licenses, if necessary to obtain information relevant to a Department decision concerning the assignment, hiring or retention of an individual, the issuance of a security clearance, the letting of a contract, or the issuance of a license, grant or other benefit.

3. A record from this system of records may be disclosed, as a routine use, to a Federal, state, local, or international agency, in response to its request, in connection with the assignment, hiring or retention of an individual, the issuance of a security clearance, the reporting of an investigation of an individual, the letting of a contract, or the issuance of a license, grant, or other benefit by the requesting agency, to the extent that the information is relevant and necessary to the requesting agency's decision on the matter.

4. A record from this system of records may be disclosed, as a routine use, in the course of presenting evidence to a court, magistrate or administrative tribunal, including disclosures to opposing counsel in the course of settlement negotiations.

5. A record in this system of records may be disclosed, as a routine use, to a Member of Congress submitting a request involving an individual when the individual has requested assistance from the Member with respect to the subject matter of the record.

8. A record in this system of records may be disclosed, as a routine use, to the Office of Management and Budget in connection with the review of private relief legislation as set forth in OMB Circular No. A-19 at any stage of the legislative coordination and clearance process as set forth in that Circular.

9. A record in this system of records may be disclosed, as a routine use, to the Department of Justice in connection with determining whether disclosure thereof is required by the Freedom of Information Act (5 U.S.C. 552).

10. A record in this system of records may be disclosed, as a routine use, to a contractor of the Department having need for the information in the performance of the contract, but not operating a system of records within the meaning of 5 U.S.C. 552a(m).

12. A record in this system may be transferred, as a routine use, to the Office of Personnel Management: for personnel research purposes; as a data source for management information; for the production of summary descriptive statistics and analytical studies in support of the function for which the records are collected and maintained; or for related manpower studies.

13. A record from this system of records may be disclosed, as a routine use, to the Administrator, General Services Administration (GSA), or his designee, during an inspection of records conducted by GSA as part of that agency's responsibility to recommend improvements in records management practices and programs, under authority of 44 U.S.C. 2904 and 2906. Such disclosure shall be made in accordance with the GSA regulations governing inspection of records for this purpose, and any other relevant (i.e. GSA or Commerce) directive. Such disclosure shall not be used to make determinations about individuals.

FORM PTO-158LS (Rev. September 1, 2010) United States Patent and Trademark Office APPLICATION FOR LIMITED RECOGNITION IN USPTO LAW SCHOOL PROGRAM FOR LAW STUDENTS TO PRACTICE BEFORE THE UNITED STATES PATENT AND TRADEMARK OFFICE									THIS SPACE FOR UNITED STATES PATENT AND TRADEMARK OFFICE USE ONLY
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 collection of information is required by 37 CFR Sections 11.5 through 11.11. This information is used by the public to register to practice before the United States Patent and Trademark Office (USPTO) and by the USPTO to determine the eligibility of the applicant to register to practice before the USPTO. The information on this form will be treated confidentially to the extent allowed under the Privacy Act and the Freedom of Information Act (FOIA). Response to this information collection is voluntary; however, if you do not provide the requested information, the USPTO may not admit you to the registration examination or register you to practice before the USPTO. This form is estimated to take 30 minutes to complete, including gathering, preparing, and submitting the information on the application to the USPTO. 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 Chief Administrative Officer, United States Patent and Trademark Office. DO NOT SEND FEES OR COMPLETED FORMS TO THIS ADDRESS. SEND TO: Mail Stop OED, United States Patent and Trademark Office, PO Box 1450, Alexandria, VA 22313-1450
1a) Legal Name	First Name Middle Name Last Name
1c) ADDRESS:	Law School Clinic address
	(street, building, suite, etc.)
1d) CITY		1e) STATE			1f) ZIP CODE		1g) DAYTIME Area Code & Phone Number
2. CITIZENSHIP (country)				3. DATE OF BIRTH (month, day, year)		4. PLACE OF BIRTH (City, State, Country)
FOR ALIENS ONLY	5. VISA CLASSIFICATION		6. PERMANENT RESIDENT OF THE UNITED STATES YES Attach copy of both sides of NO documentation of permanent residence			7. ALIEN REGISTRATION NUMBER
You are required to update the foregoing information promptly upon any change. Select and check all the following that apply. Applicants should carefully review the General Requirements Bulletin for detailed instructions on completing this application. 8 Are you presently a Registered Agent? No (go to #9) - OR - Yes. Please see #8a. 8a. My Registration No. is 9. EDUCATION: Law School information: Upon the basis of the foregoing information and any attached documents, I hereby apply for registration to practice in trademark and/or patent cases before the United States Patent and Trademark Office. I certify that each and every statement or representation inthis application is true and correct. (A willfully false statement or certification is a criminal offense and is punishable by law [18 U.S.C. § 1001].)
10. Signature of Applicant								Date

OMB No. 0651-0081 Approval Expires XX/XXXX

Law School Clinic	Trademark or Patent Clinic	Semester(s) Participating	Miscellaneous Information