Certificate Action Form {PTO-2042} | Pdf Fpdf Doc Docx | Official Federal Forms

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Certificate Action Form {PTO-2042} | Pdf Fpdf Doc Docx | Official Federal Forms

Certificate Action Form {PTO-2042}

This is a Official Federal Forms form that can be used for Patent within US Patent Office.

Alternate TextLast updated: 12/19/2006

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PTO-2042 (06-2006) Approved for use through 02/28/2009. 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 (select one) Registered Practitioner Limited Recognition Practitioner Pro Se Inventor Address to: Mail Stop EBC Commissioner for Patents P.O. Box 1450 Alexandria, VA 22313-1450 USPTO Use Only Block 1 Requestor Status 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. First (Given) Name 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 Middle Name Last (Family) Name Street Address (line 1) Street Address (line 2) City Telephone Number (select phone location) State home work cell Email Address Zip Country 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) _____________ (requestor from Block 2) this _ _______ in the State of ______ _ _______. (Notarial Seal) Block 5 ­ Identification (required) SUBSCRIBED and SWORN to before me by _________ day of ____ ____ (month), 20_ 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 Information 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 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 the 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 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. ___, in the county of ____ 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 relev

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