Data Sheet - Register of Patent Attorneys and Agents

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OMB No. 0651‐0012 | Approved through x/xx/xxxx | FORM PTO‐107A

U.S. PATENT AND TRADEMARK OFFICE

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 provide 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

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

ALTERNATE/HOME STATE

 AGENT

ALTERNATE/HOME COUNTRY

ALTERNATE/HOME ZIP CODE

 LIMITED RECOGNITION

1.

Registration Status:  ATTORNEY

2.

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 authority 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 §§ 11.10(d) and (e).

6.

 YES

 NO

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

FOR USPTO USE ONLY

AGENT:

___________________________

ATTORNEY: ___________________________
LIMITED:

___________________________

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.
7. SIGNATURE OF APPLICANT

DATE

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OMB No. 0651‐0012 | Approved for use through x/xx/xxxx | FORM PTO‐107A

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