Pre-Application Assessment Program Interest Form

OMB Control Number: 0651-0080

Expiration Date: XX/XX/XXXX

Pre-Application Assessment Program Interest Form

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The form below may be used to request participation in the Pre-Application Assessment program. Please fill in the information desired below and click on the “submit” button.

Requests to participate in Pre-Application Assessment program are granted depending upon resources, training time available, and the intended target audience for each course.

Enter Requesting Information

*Items are mandatory

*First name

*Last name

*Address 1

Address 2

*City

*State/province

*ZIP/postal code

*Country/region

*Email address

Company

Title

*Phone number

1. *Have you already filed a patent application? ☐Yes ☐No

2. *When do you plan on filing an application as a Pro Se inventor?
   In the next: ☐30 days ☐60 days ☐ 90 days ☐more than 6 months

3. *What technology area do you plan to file a patent application?

4. Please provide your USPTO customer number (if you have one)? Click or tap here to enter text.

5. *Are you registered to practice law in patent matters before the USPTO? ☐Yes ☐No

6. Do you want to be notified of future courses? ☐Yes ☐No

By completing this interest form, you authorize us to contact you for follow on questions.

Privacy Act Statement
The United States Patent and Trademark Office (USPTO) collects this information under authority of 35 U.S.C. 2(b)(2). The information you provide will be used to register to participate in Agency-sponsored events and programs designed to disseminate information to the public on topics related to patents and trademarks.  This system includes information about individuals who have requested participation in an Agency-sponsored event or program. The information 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 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; and to National Archives and Records Administration. If you do not furnish the requested information, the USPTO may not be able to process your request for participation in the event or program. The applicable Privacy Act System of Records Notice for this information request is PAT-TM-19, Dissemination Events and Registrations: Federal Register vol. 71 December 27, 2006, page 77739, available at https://www.federalregister.gov/documents/2006/12/27/E6-22122/privacy-act-of-1974-system-of-records

 

PRA Statement of Burden
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 valid OMB Control Number. The OMB Control Number for this information collection is 0651-0080. 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 Office of the Chief Administrative Officer, United States Patent and Trademark Office, P.O. Box 1450, Alexandria, VA 22313-1450 or email [email protected].