PTO/SB/121 (05-03)
Approved for use through 11/30/2005. OMB 0651-0035
U.S. Patent and Trademark Office; U.S. DEPARTMENT OF COMMERCE
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CORRESPONDENCE
ADDRESS
INDICATION FORM
Address to:
Commissioner for Patents
P.O. Box 1450
Alexandria, VA 22313-1450
Please recognize the following address as the correspondence address:
Customer Number Place Customer Number
Type Customer Number here Bar Code Label here
OR
Request for Customer Number (PTO/SB/125) submitted herewith.
in the following listed application(s) or patent(s):
Patent Number Patent Date U.S. Filing
(if appropriate) Application Number (if appropriate) Date
Typed or
Printed Name
Signature
Date
Telephone
Address of signer:
(check one)
Applicant or Patentee
Assignee of record of the entire
interest. Statement under
37 CFR 3.73(b) is enclosed.
(Form PTO/SB/96)
Attorney or Agent of record
_____________________________
( Reg. No.)
NOTE: Signatures of all the inventors or assignees of record of the entire interest or their representative(s) ar