DECLARATION FOR PATENT APPLICATION
I declare that my residence, address and citizenship
are:
Full name of sole or first inventor:
_________________________________________ Citizenship:
_________________________________________________________
Residence:
__________________________________________________________
___________________________________________________________________
Address:
____________________________________________________________
Full name of second joint inventor, if any: ___________________________________
Citizenship:
_________________________________________________________
Residence:
__________________________________________________________
___________________________________________________________________
Address:
____________________________________________________________
I am the sole inventor (or a joint inventor, if
applicable) of the subject matter for which I am seeking a patent. The specification is attached hereto (or was
filed on __________
________________ (Date) as application number
_____________________________). I have
reviewed and understand the contents of this specification. I also recognize that I must disclose any
information that is material to the examination of this application.
Under section 119 of Title 35 of the United States
Code, I claim foreign priority benefits for any foreign application(s) for a
patent or inventor’s certificate which is listed below. I have also listed below any foreign
application for a patent or inventor’s certificate which was filed prior to the
application on which my claim for priority is based.
Prior
Foreign Application(s):
______________________________ (Number)
______________________________ (Country)
______________________________ (Month/Day/Year
filed)
Priority Claimed? Yes
______ No ______
______________________________ (Number)
______________________________ (Country)
______________________________ (Month/Day/Year
filed)
Priority Claimed? Yes
______ No ______
Under section 120 of Title 35 of the United States
Code, I also claim the benefit of the following United States application(s):
United
States Applications:
____________________________ (Application Serial
Number.)
____________________________ (Date Filed)
____________________________ (Status: patented, pending, abandoned)
____________________________ (Application Serial
Number.)
____________________________ (Date Filed)
____________________________ (Status: patented, pending, abandoned)
I appoint
__________________________________________________ (Name) as my attorney and/or
agent for the purpose of prosecuting this application and for conducting all
business in connection therewith.
All telephone calls and all correspondence should be
addressed to:
______________________________________________________
(telephone number)
______________________________________________________________
(address)
All statements made herein are, to the best of my
knowledge, true. Furthermore, I
recognize that willful false statements are unlawful and are punishable by fine
or imprisonment.
___________________________________ ___________________
Signature of Inventor Date
___________________________________ ___________________
Signature of Inventor Date
