PTO-107R Reinstatement - Data Sheet - Register of Patent Attorney

OMB No. 0651‐0012 | Approved for use through XX/XX/20XX | FORM PTO‐107R

U.S. PATENT AND TRADEMARK OFFICE

REINSTATEMENT
DATA SHEET - REGISTER OF PATENT ATTORNEYS AND AGENTS
You must provide a correspondence/business name, address and telephone number in the boxes below. Government employees must p rovide the name and
address of the department or Government agency in the correspondence/business name, address and telephone number boxes. This will be published in
accordance with 37 CFR § 11.11(a). Only your correspondence/business address and telephone number will be published. COMPLETE ALL LINES
LEGAL NAME
Last Name
First Name
Middle Name
FOR USPTO USE ONLY

 Mr.  Ms.
CORRESPONDENCE/
BUSINESS ADDRESS
(street, bldg., suite,
etc.) This address will
be used for official
correspondence.

CORRESPONDENCE/BUSINESS NAME Employer, corporation, law firm, U.S. Government
agency. Indicate if student or unemployed.

REGISTRATION NUMBER

CORRESPONDENCE/BUSINESS CITY

CORRESPONDENCE/BUSINESS STATE

CORRESPONDENCE/BUSINESS COUNTRY

CORRESPONDENCE/BUSINESS ZIP CODE

CORRESPONDENCE/BUSINESS PHONE NUMBER
(daytime)

E-MAIL (primary)

E‐MAIL (secondary)

CITIZENSHIP (country)

DATE OF BIRTH (month, day, year)

ALTERNATE/HOME ADDRESS

ALTERNATE/HOME PHONE NUMBER

ALTERNATE/HOME CITY

1.

ALTERNATE/HOME STATE

ALTERNATE/HOME COUNTRY

ALTERNATE/HOME ZIP CODE

I AM APPLYING FOR REINSTATEMENT:




after being administratively suspended. Enclosed is my fee pursuant to 37 CFR § 1.21(a)(9). See 37 CFR § 11.11(f)(1).






after having resigned. Enclosed is my fee pursuant to 37 CFR § 1.21(a)(9)(ii). See 37 CFR § 11.11(f)(3).

as a former government employee. Enclosed is my fee pursuant to 37 CFR § 1.21(a)(9)(ii) and an Undertaking form.
See 37 CFR § 11.11(f)(2).
of my limited recognition. Enclosed is my fee pursuant to 37 CFR § 1.21(a)(9)(ii). See 37 CFR § 11.9(f).
after I have been suspended or excluded from practice before the USPTO. Enclosed is my fee pursuant to 37 CFR § 1.21(a)(10).
from voluntary inactive status. See 37 CFR § 11.11(d)(6).

2.

Registration Status:  PATENT ATTORNEY  PATENT AGENT  LIMITED RECOGNITION  DESIGN ATTORNEY  DESIGN AGENT
If you are an attorney, please list all States of the United States in which you are a member in good standing of the bar of the highest court
of the State: ______________________________________________________________________________________________________

3.

 YES

 NO

In the last five (5) years, have you been suspended or disbarred from practice on ethical grounds by any duly
constituted authority of a State of the United States, or in the case of a practitioner who resides in a foreign country
or is registered under 37 CFR § 11.6(c) by any duly constituted aut hority of the country in which the practitioner
resides? If YES, please attach a statement explaining when, where and the grounds for the disbarment or suspension.

4.

 YES

 NO

In the last five (5) years, have you been convicted of a felony or misdemeanor (other than a non-criminal traffic
violation) by any federal, State or other law enforcement authority? If YES, please attach a statement giving the date,
charge, and place of the offense and an explanation of the facts and circumstances leading to the conviction.

5.

 YES

 NO

Are you an employee of the United States Government? PLEASE NOTE: U.S. Government employees are not available
to accept private clients or to represent clients other than their agency before the United States Patent and
Trademark Office. 18 U.S.C. § 205; 37 CFR § 11.111.

6.

 YES

 NO

Are you a former patent examiner of the United States Patent and Trademark Office?

I hereby declare that all statements made herein of my own knowledge are true and that all statements made on information and belief are
believed to be true; and further that these statements were made with the knowledge that willful false statements and the lik e so made are
punishable by fine or imprisonment, or both, under 18 U.S.C. 1001.
7.

Signature of Applicant

Date

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OMB No. 0651‐0012 | Approved for use through XX/XX/20XX | FORM PTO‐107R

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 0651-0012. Public burden for this form is estimated to average 30 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].
DO NOT SEND FEES OR COMPLETED FORMS TO THIS ADDRESS.

PRIVACY ACT STATEMENT
The Privacy Act of 1974 (P.L. 93-579) requires that you be given certain information in connection with your submission of the
attached form related to a patent application or patent. Accordingly, pursuant to the requirements of the Act, please be advised
that: (1) the general authority for the collection of this information is 35 U.S.C. 2(b)(2); (2) furnishing of the informatio n solicited
is voluntary; and (3) the principal purpose for which the information is used by the U.S. Patent and Trademark Office is to process
and/or examine your submission related to a patent application or patent. If you do not furnish the requested information, the
U.S. Patent and Trademark Office may not be able to process and/or examine your submission, which may result in termination of
proceedings or abandonment of the application or expiration of the patent.
The information provided by you in this form will be subject to the following routine uses:
1.

The information on this form will be treated confidentially to the extent allowed under the Freedom of Information Act
(5 U.S.C. 552) and the Privacy Act (5 U.S.C 552a). Records from this system of records may be disclosed to the Department
of Justice to determine whether disclosure of these records is required by the Freedom of Information Act.

2.

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.

3.

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, to whom the record pertains, when the individual has requested assistance from the Member with
respect to the subject matter of the record.

4.

A record in this system of records may be disclosed, as a routine use, to a contractor of the Agency having need for the
information in order to perform a contract. Recipients of information shall be required to comply with the requirements
of the Privacy Act of 1974, as amended, pursuant to 5 U.S.C. 552a(m).

5.

A record related to an International Application filed under the Patent Cooperation Treaty in this system of records may
be disclosed, as a routine use, to the International Bureau of the World Intellectual Property Organization, pursuant to the
Patent Cooperation Treaty.

6.

A record in this system of records may be disclosed, as a routine use, to another federal agency for purposes of National
Security review (35 U.S.C. 181) and for review pursuant to the Atomic Energy Act (42 U.S.C. 218(c)).

7.

A record from this system of records may be disclosed, as a routine use, to the Administrator, General Services, or his/her
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.

8.

A record from this system of records may be disclosed, as a routine use, to the public after either publication of the
application pursuant to 35 U.S.C. 122(b) or issuance of a patent pursuant to 35 U.S.C. 151. Further, a record may be
disclosed, subject to the limitations of 37 CFR 1.14, as a routine use, to the public if the record was file d in an application
which became abandoned or in which the proceedings were terminated and which application is referenced by either a
published application, an application open to public inspection or an issued patent.

9.

A record from this system of records may be disclosed, as a routine use, to a Federal, State, or local law enforcement
agency, if the USPTO becomes aware of a violation or potential violation of law or regulation.