|
PATENT RECORDATION FORM
COVER SHEET
|
Attorney
Docket No.
___________________
|
|
To
the Commissioner for Patents:
Please record the attached original document or
copy thereof.
|
|
1. Name of conveying party(ies):
(1)
____________________________________
Name of Party Assigning Rights
(2)
____________________________________
Name of Party Assigning Rights
Additional
name(s) of conveying party(ies) attached? [
] Yes [ ]
No
|
2.
Name and address of receiving party(ies):
Name:
________________________________
Name of Receiving Party(ies)
Internal Address: ________________________
Street
Address: _________________________
_____________________________________
|
|
3.
Nature of Conveyance:
[ ] Assignment
[ ]
Merger [
] Security Agreement
[ ] Change of
Name [
] Other
_________________________________________
If Other, Explain
Execution
Date: _________________________
List Date(s) Document Executed
|
City ________________ State _____ ZIP _____
Additional
name(s) & address(es) attached?
[ ] Yes [
] No
|
|
4A.
Application No.(s)
______________________________________
Serial No.(s) - if Applicable
If
this document is being filed together with a new
application, the execution date(s) of the application is: ___________________________________
Execution Date(s) of Appln. - If
applicable
Additional
numbers attached? [ ]
Yes [ ] No
|
4B.
Patent No.(s)
______________________________________
Patent No.(s) - if Applicable
Additional
numbers attached? [ ]
Yes [ ] No
|
|
5.
Name and address of party to whom
correspondence
concerning document should be
mailed:
|
6.
Total number of applications and patents
involved: [ ]
|
|
Name:
__________________________
Responsible Attorney
|
7.
Total fee (37 CFR 3.41):.....$
___________
|
|
Street
Address:__________________________
______________________________________
City:
_______________ State: _____ ZIP: _____
|
8.
Method of Payment
[ ]
Enclosed
[ ]
The Commissioner is authorized to charge payment of any
additional recording fees or credit any overpayment to
deposit account No. __________________________.
|
|
DO
NOT USE THIS SPACE
|
|
9.
Statement and signature.
To
the best of my knowledge and belief, the foregoing
information is true and correct and any attached copy is a
true copy of the original document.
Name
of Person Signing
____________________
Signature
Date
Total
number of pages including cover sheet, attachments and
document: [ ]
|
