Aorney Docket No.:
DECLARATION (37 CFR 1.63) FOR UTILITY OR DESIGN APPLICATION USING AN APPLICATION DATA
SHEET (37CFR 1.76)
Title of
Inven"on
As the below named inventor, I hereby declare that:
This declaraon is directed to:
The aached applicaon, or
United States Applicaon or PCT internaonal applicaon number _________ %led on _________.
The above-iden%ed applicaon was made or authorized to be made by me.
I believe that I am the original inventor or an original joint inventor of a claimed invenon in the
applicaon.
I hereby acknowledge that any willful false statement made in this declaraon is punishable under 18
U.S.C. 1001 by %ne or imprisonment of not more than %ve (5) years, or both.
Power of A%orney
As a named inventor, I hereby appoint the following registered praconer(s) to prosecute this
applicaon and to transact all business in the Patent and Trademark O2ce connected therewith,
Customer Number 54000.
Correspondence
Direct all correspondence to Customer Number 54000.
LEGAL NAME OF INVENTOR:
Inventor : _____ ______
Signature: _____ ___________ ________________ Date: _____ __ ____ _________ ____________
Note: An applicaon data sheet (PTO/AIA/14 or equivalent), including naming the enre invenve enty, must accompany this
form. Use an addional form of the same for each addional inventor.
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