Form Pto-1595 (Rev. 03-11) - Recordation Form Cover Sheet
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U.S. DEPART M E N T OF COMMERCE
Form PTO-1595 ( Rev . 03 -11 )
O M B No. 0651-0027 (exp. 04/30/2015)
United States Patent and Trademark Off i ce
RECORD A TION FO RM C O VER SHEET
P A T EN T S O NLY
To the Director of the U.S. Patent and Trademark Off i ce: Please record the attached documents or t h e new address(es) belo w .
1. Name o f c o n v e y i n g p ar t y ( ies)
2. Name a n d a dd ress o f r ece i v i n g p ar t y ( ies)
Na m e: _ _____ _ _____ _ __ _ _______ _ _____ _ ______
Inte r nal Add r e ss : _ _ _____ _ _______ _ _____ _ ______
___________________________________________________
Additional name ( s) of conveying party(ies) attached?
Yes
No
3. Na tu re o f c onv e y a n ce / Exec ut i o n Da t e ( s ) :
St r eet Add r e ss : _____ _ _ _ _______ _ _____ _ _____ _ _
E x e c ution Date (s) ____ _ _ _ _______ _ _____ _ _____ _ __
___________________________________________________
A ss ign m e n t
Me r ger
Ci t y : ___________ _ _____ _ _______ _ _____ _ ______
Se c u r i t y Ag r ee m ent
Change o f N a m e
J oint Re s ea rc h Ag r e e m ent
State: _____ _ _____ _ ____ _ _______ _ _____ _ ______
Go v ernment Inter e st Ass i g nment
Count r y : ___________ _ __ _ ____ Z ip: _______ _ ______
E x e c utive Or der 9424, Co n fi rm ato r y L i c en s e
O the r ___ _ _____ _ _____ __ _______ _ _____ _ ___
Y e s
N o
Addi t io n al n a m e(s) & add r e s s ( es) a tt a ch e d?
4 . A ppli ca tion or p a t e nt numb er ( s ):
T his doc u m ent is being f iled together w ith a new ap p l ic ation.
A. Patent Appli c ation No. (s )
B. Patent No. (s )
Additional numbers attached?
Yes
No
5. Name and address to whom correspondence
6 . Tot a l num be r of a ppli c a tions a nd p a t e nts
c on cer ning do c um e nt s hould be m a il e d:
i nvo l ve d: _____ _ _____ _ _ _ _______ _ ______
Na m e: _ _____ _ _____ _ __ _ _______ _ _____ _ _____ _ _
7. Total fe e ( 37 C F R 1.21(h) & 3.41) $__ _ _____ _ _ _ _
Inte r nal Add r e ss : __ _ ____ _ _______ _ _____ _ _____ _ _
___________________________________________
Autho ri z ed to be c ha r ged to depo s it a c count
En c lo s ed
St r eet Add r e ss : _ _____ _ _ _ _______ _ _____ _ _____ _ __
None r equi r ed
(go v ern m ent i nter e st n ot a ff e cti n g t i tle)
___________________________________________
8. Pa y m e n t I nfo rma t i o n
Ci t y : ___________ _ _____ _ _______ _ _____ _ _____ _ _
State:_____ _ _____ _ ____ _ ____ Z ip: _______ _ _____ _ _
Phone N u m be r : ___ _ ____ _ _______ _ _____ _ _____ _ __
Depo s it A cc ount N u m b er _______ _ _____ _ ____
Docket N u mber: ___ _ _____ __ _______ _ _____ _ _____
Autho ri z ed U s er Na m e __ _ _______ _ _____ _ ___
E m ail Add r e ss: _ __ _ _____ _ _______ _ _____ _ _____ _ _
9 . Si gn a tu re :
Signatu r e
D ate
Total number of pages including cover
sheet, attachments, and documents:
Na m e o f Pe rs on Signing
D ocu me n t s t o be r eco r d e d ( in c l ud i n g co v er s he et ) s h o u ld be f a xed to (571) 273-0140, or m a i l e d to:
M a i l S top As s i g n me nt R e c o r d at i o n S e r vi c e s , D i r e c tor o f the USP T O , P . O.B ox 1 45 0 , A le x a n d r i a , V. A. 2 231 3- 1 4 50
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