PTO-2042 (07-2009) Approved for use through 02/29/2012. OMB 0651-0045 U.S. Patent and Trademark Office; U.S. DEPARTMENT OF COMMERCE Under the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. Certificate Action Form USPTO Use Only Address to: Mail Stop EBC Commissioner for Patents P.O. Box 1450 Alexandria, VA 22313-1450 Block 1 Requestor Status (select one) Registered Practitioner Limited Recognition Practitioner Pro Se Inventor Practitioner Registration Number or Limited Recognition Number: Practitioners ONLY Check box to indicate that additional customer numbers are listed on an attached sheet Customer Numbers – Enter in space(s) provided below A customer number is an application electronic tracking number assigned by the USPTO that associates your certificate with one or more patent applications. Please see the instructions if you don't already have a customer number http://www.uspto.gov/ebc/digitalcert.htm. Customer Number Customer Number Customer Number Customer Number Customer Number Customer Number Block 2 - Requestor Information (All Information Required) Name as it should appear on your PKI Certificate or as it appears on previous certificates in cases of recovery. If this is a name change (for registered individuals or persons granted limited recognition, the name provided must correspond to Office of Enrollment and Discipline records), please enter the name under which the certificate was previously created below and enter new name in space provided: Previous Name First (Given) Name Middle Name Last (Family) Name Street Address (line 1) Street Address (line 2) City State Zip home work cell Telephone Number (select phone location) Country Email Address Block 3 - Type of Action Requested (you must select at least 1) Request a new PKI Certificate (I have never been issued a PKI Certificate by USPTO) Recover previously issued PKI Certificate (select 1 reason) -- Forgotten or Lost Password -- Corrupted or Lost Profile -- Other reason (Please explain): Associate current PKI Certificate with the customer numbers detailed in Block 1 Revoke current PKI Certificate Name Change (see Block 2 above) Other – Describe in Detail: Block 4 – Signature (required) I have read and understand the Subscriber Agreement (as listed on www.uspto.gov/ebc) and my signature on this document, by hand, is my agreement to abide by the Agreement and the rules and policies of the USPTO regarding the Agreement. I certify that the information, statements and representations provided by me on this form are true and accurate to the best of my knowledge. I understand that a willfully false certification is a criminal offense and is punishable by law (18 U.S.C. 1001). Signature Required (requestor from Block 2) Date (mm/dd/yyyy) Block 5 – Identification (required) SUBSCRIBED and SWORN to before me by _________ day of ____ ____ (month), 20_ _____________ (requestor from Block 2) this _ ___, in the county of ____ _______ in the State of ______ _ (Notarial Seal) _______. Notary Public _____________________ (signature) MY COMMISSION EXPIRES: ________________________________ This collection of information is required under 35 U.S.C. § 2 and § 122. This information is provided by the public as part of the request for or revocation of a U.S. Patent and Trademark Office (USPTO) public key certificate or to request recovery of your private encryption key. The USPTO will use this information in the process of issuing or revoking a public key certificate or recovering an encryption key. The information on this form will be treated confidentially to the extent allowed under the Government Paperwork Elimination Act, Freedom of Act (FOIA), and the Privacy Act. In order to access information that is released through encrypted communication, you must supply the requested information in order for the USPTO to Information issue the necessary digital identity and encryption services. This form is estimated to take 30 minutes to read the instructions, gather the necessary information, complete the form, read and sign the subscriber’s agreement, and submit the form to USPTO. Any comments on the amount of time you require to complete this form and/or suggestions for reducing this burden should be sent to the Chief Information Officer, U.S. Patent the and Trademark Office, U.S. Department of Commerce, P.O. Box 1450, Alexandria, VA 22313-1450. DO NOT SEND THE COMPLETED FORM TO THIS ADDRESS. SEND TO: Mail Stop EBC, Commissioner for Patents, P.O. Box 1450, Alexandria, VA 22313-1450. American LegalNet, Inc. www.FormsWorkFlow.com Privacy Act Statement This information is collected under the authority of 35 USC 2 and 122. This information is also being collected in conjunction with the provisions of the Government Paperwork Elimination Act. This information will only be used by the U.S. Patent and Trademark Office (USPTO) staff to issue and revoke digital certificates and to recover keys. It is requested that you supply this information so that the USPTO can authorize the creation of a digital certificate. This digital certificate enables the USPTO to issue the cryptographic “keys” necessary to provide you with a digital identity and to support encrypted communication between you and the USPTO. This information will be used to construct a unique name (distinguished name) and to communicate with you about the certificate grant and software distribution process. Furnishing the information on this form is voluntary, but failure to do so may result in disapproval of this request. The information provided by you in this form will be subject to the following routine uses: 1. This information may be disclosed to Federal, state, local, or foreign agencies responsible for investigating, prosecuting, enforcing, or implementing laws, contracts, rules, or regulations, if these records indicate a violation or a potential violation of a law or contract. These violations or potential violations can be civil, criminal, or regulatory in nature and can arise from general or particular program statutes or contracts, rules, regulations, or from the necessity of protecting an interest of the Department. 2. A record from this system of records may be disclosed to a Federal, state or local agency maintaining civil, criminal or other relevant enforcement information or other pertinent information, such as current licenses, if necessary to obtain information relevant to a Department decision concerning the assignment, hiring or retention of an individual, the issuance of a security clearance, the letting of a contract, or the issuance of a license, grant or other benefit. 3. A record from this system of records may be disclosed in the course of presenting evidence to a court, magistrate, or administrative tribunal, including disclosures to opposing counsel in the course of settlement negotiations. 4. A record in this system of records may be disclosed to a member of Congress or to a congressional staff member in response to an inquiry of the Congressional office made at the written request of the constituent about whom the record is maintained. 5. A record in this system of records may be disclosed to the Office of Management and Budget in connection with the review of private relief legislation (as set forth in OMB Circular No. A-19) at any stage of the legislative coordination and clearance process as described in the Circular. 6. A record in this system of records may be disclosed to the Department of Justice to determine whether disclosure is required by the Freedom of Information Act (FOIA). 7. The information may be disclosed to the agency contractors, grantees, experts, consultants, or volunteers who have been engaged by the agency to assist in the performance of a service related to this system of records and who have need to have access to the records in order to perform the activity. Recipients of information shall be required to comply with the requirements of the Privacy Act of 1974, as amended, pursuant to 5 USC 552a(m). 8. The information may be disclosed to the Office of Personnel Management (OPM) for personnel research purposes as a data source for management information, for the production of summary descriptive statistics and analytical studies in support of the function for which the records are collected and maintained, or for related man-power studies. 9. Records from this system of records may be disclosed to the National Archives and Records Administration or to the General Services Administration for records management inspections conducted under 44 USC §§ 2904 and 2906. 10. When a record on its face, or in conjunction with other records, indicates a violation or potential violation of law, whether it is civil, criminal, or regulatory in nature, and whether it arises from a general or particular program statute, a regulation, rule, or order, the record may be disclosed to the appropriate Federal, foreign, state, local or tribal agency, or to other public authorities responsible for enforcing, investigating, or prosecuting violations, or to those agencies charged with enforcing or implementing statutes, rules, regulations, or orders, if it is determined that the information is relevant to any enforcement, regulatory, investigative, or prosecutive responsibility of the receiving entity. American LegalNet, Inc. www.FormsWorkFlow.com