Doc Code: PEER.CONSENT Document Description: Request for Peer Review Pilot PTO/SB/422 (11-10) Certification and Request to Participate in FY 2011 Pilot Program Concerning Public Submission of Peer Reviewed Prior Art First Named Inventor: Application Number (if known): Title of Invention: Part I – Request to Participate in Pilot Applicant provides express written consent under 35 USC 122 (c) for the USPTO to accept prior art references and comments by third party submitter, Peer To Patent, to be considered during the examination of the above identified application participating in the Peer Reviewed Prior Art Pilot Project. No other consents are provided herein. Subject to the conditions listed below in Part II, Applicant hereby requests that the requirements of 37 CFR 1.99(d) and 37 CFR 1.291(b) be waived by the USPTO for the aboveidentified application participating in this pilot. Part II – Additional Conditions Necessary For Waiver 1. Applicant certifies the following: a. the above-identified application has not itself been published by the USPTO more than one month prior to the filing of this Request; b. the above-identified application contains claimed subject matter believed to be classifiable in at least one of the classes/subclasses listed at http://www.uspto.gov/patents/init_events/class_subclasses_FY2011pilot.jsp; c. Applicant agrees to full participation in the pilot program; and d. (including this request) Applicant or Applicant’s assignee has not submitted more than 25 applications for participation in the Peer Reviewed Prior Art Pilot Project. 2. Through submission of this form, Applicant provides consent to the following: a. the submission of up to six patents or publications by the third party submitter (Peer To Patent) and comments describing the relevance of the document to the disclosed invention; and b. the filing of the submission no later than eighteen (18) weeks after publication of the aboveidentified Application. Note: Applicant shall not be required to submit an Information Disclosure Statement under 37 CFR 1.97 and 1.98 to ensure that the references submitted by third party submitter (Peer To Patent) are considered by the examiner. No fees are required in making this request. Signature Date Name (Printed/Typed) Registration Number Telephone No. E-mail Note: Signature of all the inventors or assignees of record of the entire interest or their representative(s) are required in accordance with 37 CFR 1.33 and 11.18. Please see 37 CFR 1.4(d) for the form of the signature. If necessary, submit multiple forms for more than one signature, see below*. *Total of _________ signed forms are submitted. 68%0,7 &203/(7(' )250 E\ ()6:HE RU E\ )$; WR  American LegalNet, Inc. www.FormsWorkFlow.com 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 information 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 filed 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. American LegalNet, Inc. www.FormsWorkFlow.com