Form PTO 2030 PTO 2030 Application for Form ID

PTO Form 2030 OMB 0651-0041 (Exp. X/XX/XXXX)

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.

LAST NAME: (TO BE COMPLETED BY STAFF MEMBER)

USER ID NUMBER:

U.S. PATENT AND TRADEMARK OFFICE

PUBLIC SEARCH FACILITIES

APPLICATION FOR PUBLIC USER ID

ACKNOWLEDGEMENT

In order to be issued a User Pass which will permit access to the Public Search Facilities and track use of the facilities and services, it is necessary to execute the following acknowledgement.

I acknowledge that the use of the Patent and Trademark Office search facilities is a privilege extended to the public. By accepting the User ID and the entitlements thereunder, I agree to comply with, and be bound by, all Patent and Trademark rules and regulations governing the use of Patent and Trademark collections, services, facilities, reading rooms, and other premises of the Patent and Trademark Office. I have received and read, “Conduct on Patent and Trademark Premises”.

Date: _______________________________ Signature:_______________________________________________

NAME: (PLEASE PRINT) _______________________________________________________________

ADDRESS: _______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

TELEPHONE: (Home)__________________________________(Work)___________________________________________

FOR STAFF USE ONLY

Form of Identification Submitted: Identification Card Number:

______________________________________________ _____________________________________________________

Restrictions (If Any:)

Paperwork Reduction Act Statement

This collection of information is authorized by 35 U.S.C. § 2, and 41 CFR Part 102-81 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

Privacy Act Statement

The United States Patent and Trademark Office (USPTO) collects this information under authority of 41 CFR

102-81. 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