PTO 158 T - APPLICATION FOR RECOGNITION TO PRACTICE BEFORE THE UNITED STATES PATENT AND TRADEMARK OFFICE UNDER 37 CFR § 11.14(c)

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OMB No. 0651‐0012 | Approved through x/xx/xxxx | FORM PTO‐158T

U.S. PATENT AND TRADEMARK OFFICE

APPLICATION FOR RECOGNITION TO PRACTICE BEFORE THE UNITED STATES PATENT AND
TRADEMARK OFFICE UNDER 37 CFR § 11.14(c) BY A FOREIGN RESIDENT
1A. LEGAL NAME

Last Name

First Name

Middle Name

FOR USPTO USE ONLY

 Mr.  Ms.
1B. ADDRESS
(street, bldg.,
suite, etc.) This
address will be
used for official
correspondence.

Employer, corporation, law firm, U.S. Government agency. Indicate if student or unemployed.

1C. CITY

1D. STATE

1E. COUNTRY

1F. ZIP CODE

1G. PHONE NUMBER (daytime)

1H. E-MAIL (primary)

1I. E‐MAIL (secondary)

2. CITIZENSHIP (country)

3. DATE OF BIRTH (month, day, year)

4. PLACE OF BIRTH (City, State, Country)

You are required to update the foregoing information promptly upon any change. Check all the following that apply.
5.

APPLICATION FEE: (PLEASE REFER TO THE GENERAL REQUIREMENTS BULLETIN AND 37 CFR § 11.7)

OR


6.

Enclosed is the non‐refundable $110.00 application fee set forth in 37 CFR § 1.21(a)(1)(i).
Enclosed is the $1,680.00 fee set forth in 37 CFR § 1.21(a)(10).

PREVIOUSLY APPLIED FOR RECOGNITION:


I previously applied for recognition to practice before the United Stated Patent and Trademark Office in trademark matters or received
from the Office of Enrollment and Discipline an evaluation of my qualifications. Enclosed is my application fee under 5.
Date of Previous Application: _____ / _____ / ________

7.

Name on Application, if different __________________________________

BASIS FOR RECOGNITION:


I am in good standing before the Trademark Office of: (list all that apply)
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

8.

BAR MEMBERSHIP:


I am an active attorney in good standing in each of the following courts or jurisdictions. Please provide the corresponding bar
membership numbers and enclose a proof of your status as an attorney.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

OMB No. 0651‐0012 | Approved for use through x/xx/xxxx | FORM PTO‐158T

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BACKGROUND INFORMATION: Candor and truthfulness are significant elements of fitness relevant to practice before the United States Patent and
Trademark Office. You should, therefore, provide the Office of Enrollment and Discipline with all available information, however unfavorable, even if
its relevance is in doubt, with regard to the questions asked below. For each question answered “YES,” provide a detailed statement setting forth all
relevant facts and dates along with verified copies of relevant documents. Your responses must be updated, as necessary, prior to your registration.
Any documents, evidence or proofs previously filed in a prior application need not be resubmitted unless your response to a question must be
changed. Failure to disclose the requested information may result in denial of registration or in disciplinary proceedings, should you become
registered. See 37 CFR §§ 11.7(a)(2)(ii), 11.19, and 11.801.

9.

 YES

 NO

Have you ever been disciplined, reprimanded, suspended, expelled, or agreed to surrender a license or have any
charges ever been proffered against you in connection with your practice before any Federal or State court,
municipal bureau, commission, office, or agency of any kind or character?

10.

 YES

 NO

Have you ever been arrested, charged, or held by Federal, State, or other law enforcement authorities for any
violation of any Federal or State law, or any country or municipal law, regulation, or ordinance? (Do not
include any misdemeanor before your 16th birthday or traffic violations for which the fine was $100 or less.)

11.

 YES

 NO

Have you ever been disciplined, reprimanded, suspended, expelled, or asked to resign or withdraw from any
educational institution, or have you resigned or withdrawn from any such institution in time to avoid a request to
resign or in time to avoid discipline, reprimand, suspension, or expulsion for conduct involving dishonesty, fraud,
misrepresentation, or deceit?

12.

 YES

 NO

Have you ever been disciplined, reprimanded, or suspended in any job for conduct involving dishonesty, fraud,
misrepresentation, deceit, or for any violation of Federal or State laws or regulations?

13.

 YES

 NO

Have you ever been fired or discharged from any job, or have you been asked to resign or quit for conduct
involving dishonesty, fraud, misrepresentation, deceit, or any violation of Federal or State laws or regulations?

14.

 YES

 NO

Have you ever resigned or quit a job when you were under investigation or inquiry for conduct which could have
been considered as involving dishonesty, fraud, misrepresentation, deceit, or violation of Federal or State laws or
regulations, or after receiving notice or been advised of possible investigation, inquiry, or disciplinary action for
such conduct?

15.

 YES

 NO

Have you ever been discharged from military service under conditions “other than honorable,” or by reason of
the sentence of a Court Martial or being dropped from the rolls?

16.

 YES

 NO

Are you delinquent on any State or Federal debt? (Include delinquencies arising from Federal or State taxes,
loans, overpayment of benefits, and other debts to the U.S. Government and defaults on Federally guaranteed or
insured loans such as student and home mortgage loans.)

Upon the basis of the foregoing information and any attached documents, I hereby apply for recognition to practice in trademark matters
before 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 like so made are punishable by fine or imprisonment, or both, under 18 U.S.C. 1001.
17.

Signature of Applicant

Date

MAIL COMPLETED APPLICATION TO:
MAIL STOP OED, UNITED STATES PATENT AND TRADEMARK OFFICE, P. O. BOX 1450, ALEXANDRIA, VA 22313‐1450

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OMB No. 0651‐0012 | Approved for use through x/xx/xxxx | FORM PTO‐158T

PRA Act Statement
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 currently 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 Chief Administrative Officer, United States Patent and Trademark
Office, P.O. Box 1450, Alexandria, VA 22313-1450 or email [email protected].

Privacy Act Statement
The United States Patent and Trademark Office (USPTO) collects this information under authority of 5 CFR 339.205. The
information in this system of records is used to manage biographical information, personal and professional qualifications,
character and fitness report, investigations of an applicant’s suitability or eligibility for registration to practice before the USPTO,
undertakings of former patent examiners, current address, and status information. 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: 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, 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 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; 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 (OPM) for
personnel research purposes; to National Archives and Records Administration for inspection of records. Failure to provide any
part of the requested information may result in an inability to process requests for access and information. The applicable Privacy
Act System of Records Notice for this information is COMMERCE/PAT–TM–1 Attorneys and Agents Registered to Practice Before
the Office available at Federal Register /Vol. 78, No. 53 /Tuesday, March 19, 2013 /Notices
https://www.federalregister.gov/documents/2013/03/19/2013-06254/privacy-act-of-1974-system-of-records