Application Serial Number:  ______________________ (Or attach application with request)

Filed:  _________________________

Titled:  ________________________________________________________________

Applicant(s):  __________________________________________________________


I hereby request the Commissioner of Patents and Trademarks to publish the regularly filed patent application identified above as a Statutory Invention Registration.  I also waive the right to receive a United States patent on the same invention claimed in that application.  I also understand that upon publication of the Statutory Invention Registration, this waiver will effectively waive my right to receive a United States patent on the invention claimed in the Statutory Invention Registration.


In my opinion, the disclosures and claims of the above patent application meet the requirements of section 112 of Title 35 of the United States Code.


I have enclosed the required fee for requesting publication of a Statutory Invention Registration which amounts to $ ____________________.


List below the name(s) of not more than 3 registered patent attorneys or agents if you wish to have their names printed on the front page of the Statutory Invention Registration:






List below the name of any assignee whose name you wish to be printed on the Statutory Invention Registration:


_____________________________________________________________ (Name)

___________________________________________________________ (Address)

______________________________________ (State of Incorporation, If Applicable)




___________________________________                       ___________________

Signature of Applicant                                                            Date




___________________________________                       ___________________

Signature of Assignee                                                             Date




___________________________________                       ___________________

Signature of Attorney/Agent                                       Date