U.S. PATENT AND TRADEMARK OFFICE | Approved through 2/28/2021 | APPLICATION FOR REGISTRATION TO PRACTICE BEFORE THE UNITED STATES PATENT AND TRADEMARK OFFICE 1A. LEGAL NAME Mr. Ms. Last Name First Name Middle Name FOR USPTO USE ONLY 1B. NAME SHOWN ON VALID GOVERNMENT ID same as above 1C. 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. REASONABLE ACCOMMODATION REQUEST ATTACHED 1D. CITY 1E. STATE 1F. COUNTRY 1G. ZIP CODE 1H. PHONE NUMBER (daytime) 1I. E - MAIL (primary) (secondary) 2. CITIZENSHIP (country) 3. DATE OF BIRTH (month, day, year) 4. PLACE OF BIRTH (City, State, Country) FOR ALIENS ONLY 5. VISA CLASSIFICATION 6. PERMANENT RESIDENT OF THE UNITED STATES YES NO Attach copy of both sides of permanent residence documentation 7. ALIEN REGISTRATION NUMBER You are required to update the foregoing information promptly upon any change. Check all the following that apply. Applicants should carefully review the General Requirements Bulletin for detailed instructions on completing this application. 8A. APPLICATION FEE: (PLEASE REFER TO THE GENERAL REQUIREMENTS BULLETIN AND 37 CFR 247 11.7) OR E 0.00 application fee set forth in 37 CFR 247 1.21(a)(1)(i). Enclosed is the $1,600.00 fee set forth in 37 CFR 247 1.21(a)(10). 8B. REGISTRATION EXAMINATION FEE: I will utilize a commercial test administration service. Enclosed is the Government registration examination fee of $200 .00 for test administration by a commercial entity. 37 CFR 247 1.21(a)( 1)(ii)(A) . See the General Requirements Bulletin for information about fees that may be charged by the commercial test administration service. 9. WAIVER OF EXAMINATION: I AM A FORMER USPTO EMPLOYEE AND SATISFY THE REQUIREMENTS OF: 37 CFR 247 11.7(d)(1) . 37 CFR 247 11.7(d)(2) . 37 CFR 247 11.7(d)(3) . Enclosed is the application fee under 8A , above. 10. PREVIOUSLY PASSED EXAMINATION: I passed an examination on / / . Enclosed is the required fee of $2 00.00 (37 CFR 247 1.21(a)(2)) and a completed data sheet. 1 1 . PREVIOUSLY APPLIED FOR ADMISSION: I previously applied for admission to the registration examination or requested the Office of Enrollment and Discipline to ev aluate my scientific and technical qualifications. Enclosed is my application fee under 8A , along with the registration exam fee under 8B . Date of Previous Application: / / Name on Application, if different 1 2 . PREVIOUSLY REGISTERED TO PRACTICE: I was previously registered to practice in patent cases before the United States Patent and Trademark Office as an attorney or agent. Registration No. 1 3 . BAR MEMBERSHIP: I am a member in good standing of the bar of the highest court of a State or Territory of the United States. A list of all sa id courts and corresponding bar membership numbers(s) follows: American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 | Approved for use through 2/28/2021 | BACKGROUND INFORMATION: Candor and truthfulness are significant elements of fitness relevant to practice before the United St ates Patent and Trademark Office. You should, therefore, provide the Office of Enrollment and Discipline with all available informa tion, however unfavorable, even if tement setting forth all relevant facts and dates along with verified copies of relevant documen ts. 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 q uestion must be changed. Failure to disclose the requ ested information may result in denial of registration or in disciplinary proceedings, should you become registered. See 37 CFR 247247 11.7(a)(2)(ii), 11.19, and 11.801. 14. YES NO Have you ever been disciplined, reprimanded, suspended, expelled, or agreed to surrender a license or h ave 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? 15. 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 traffi c violations for which the fine was $100 .00 or less.) 16. 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? 17. 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? 18. 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 ? 19. 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? 20. YES NO sentence of a Court Martial or being dropped from the rolls? 21. 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.) 22. EDUCATION: List all degrees conferred. Attach any required documentation as discussed in the General Requirements Bulletin. If you applied previously for an exam, please see must submi t. Degree Received as indicated on Transcript College Date Received Major Subject as indicated on Transcript Upon the basis of the foregoing information and any attached documents, I hereby apply for registration to practice in patent 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 w ere 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. 23. SIGNATURE OF APPLICANT DATE MAIL COMPLETED APPLICATION TO: MAIL STOP OED, UNITED STATES PATENT AND American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3 | Approved for use through 2/28/2021 | Under the Paperwork Reduction Act of 1995, no person is required to respond to a collection of information unless it displays a valid OMB control number. This collection of information is required by 37 CFR 247247 11.5 through 11.11. This information is used by t he public to register to pr actice before the United States Patent and Trademark Office (USPTO) and by the USPTO to determine the eligibility of the applicant to apply to register to practice before the USPTO. The information on this form will be treated confidentially to the extent allowed under the Privacy Act and the Freedom of Information Act (FOIA). Response to this information collection is voluntary; however, if you do not provide the requested information, the USPTO may not admit you to the registration examinat ion or register you to practice before the USPTO. This form is estimated to take 30 minutes to complete, including gathering, preparing, and submitting the information on the application to the USPTO. Any comments on the amount of time required to complete this form and/ or suggestions for reducing this burden, should be sent to the Chief Information Officer, United S