Provisional Application For Patent Cover Sheet
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PTO/SB/16 (12-97)
Approved for use through 1/31/98. OMB 0651-0037
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.
PROVISIONAL APPLICATION FOR PATENT COVER SHEET
This is a request for filing a PROVISIONAL APPLICATION FOR PATENT under 37 CFR 1.53 (c).
INVENTOR(S)
Residence
Given Name (first and middle [if any])
Family Name or Surname
(City and either State or Foreign Country)
Additional inventors are being named on the ___ separately numbered sheets attached hereto
TITLE OF THE INVENTION (280 characters max)
CORRESPONDENCE ADDRESS
Direct all correspondence to:
Place Customer Number
Customer Number
Bar Code Label here
Type Customer Number here
OR
Firm or
Beck & Tysver, P.L.L.P.
Individual Name
1011 First Street South
Address
Suite 440
Address
Hopkins
MN
55343
City
State
ZIP
(612) 933-3331
USA
(612) 933-3049
Country
Telephone
Fax
ENCLOSED APPLICATION PARTS (check all that apply)
Number of Pages
Specification
Small Entity Statement
Number of Sheets
Drawing(s)
Other (specify)
METHOD OF PAYMENT OF FILING FEES FOR THIS PROVISIONAL APPLICATION FOR PATENT (check one)
FILING FEE
A check or money order is enclosed to cover the filing fees
AMOUNT ($)
The Commissioner is hereby authorized to charge filing
$75.00
fees or credit any overpayment to Deposit Account Number:
The invention was made by an agency of the United States Government or under a contract with an agency of the
United States Government.
No.
Yes, the name of the U.S. Government agency and the Government contract number are:
Respectfully submitted,
/
/
Date
SIGNATURE
35,726
Daniel A. Tysver
REGISTRATION NO.
TYPED or PRINTED NAME
(if appropriate)
(612) 933-3043
Docket Number:
TELEPHONE
USE ONLY FOR FILING A PROVISIONAL APPLICATION FOR PATENT
Burden Hour Statement: This form is estimated to take 0.2 hours to complete. Time will vary depending upon the needs of the individual case.
Any comments on the amount of time you are required to complete this form should be sent to the Chief Information Officer, Patent and
Trademark Office, Washington, DC 20231. DO NOT SEND FEES OR COMPLETED FORMS TO THIS ADDRESS. SEND TO: Box Provisional
Application, Assistant Commissioner for Patents, Washington, DC 20231.
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