Patent Electronic System Verification Form
Legal Form Number | PTO-2042a |
Court | United States Patent and Trademark Office |
Section | United States Patent and Trademark Office |
PTO‐2042a (01‐2019)
Patent Electronic Address to: USPTO Use Only
System Verification
Mail Stop EBC
Commissioner for Patents
Form P.O. Box 1450
Alexandria, VA 22313‐1450
Block 1 ‐ Requestor Status
Please refer to form fill instructions to minimize processing delays
(select one) Practitioner Registration Number or Limited Practitioners ONLY
☐ Recognition Number: Check box to indicate that additional
Registered Practitioner customer numbers are listed on an
Limited Recognition Practitioner ☐ attached sheet ☐
Se Inve r ☐Pro nto
Customer Numbers – Enter in Space(s) Provided Below
A customer number is an application electronic tracking num ber assigned by the USPTO that associates your Patent Electronic System
account with one or more patent applications. Please see the ins tructions if you don't already have a customer number.
Customer Number Customer Number Customer Number Customer Number Customer Number Customer Number
Block 2 ‐ Requestor Information (All Information Required)
First (Given) Name Middle Name Last (F amily) Name
Street Address (line 1)
Street Address (line 2)
City State Zip Country
Telephone Number □home U TO.gov
(select phone location
SP
) □work Email
□cell Address
Block 3 ‐ Type of Action Requested (Must Select at Least One)
☐
Request a new Patent Electronic System account
☐
Update Patent Electronic System account
‐‐ USPTO.gov email address has been changed
Previous email addre ss:
☐
This is a name change.
For registered practitioners or practitioners granted lim ited recognition, the name provided must correspond to Office of
Enrollment and Discipline records. Please enter the name under wh ich the Patent Electronic System account was previously created
below, and enter new name in space provided in Block 2:
Previous Name:
☐
Associate current Patent Electronic System account with the customer numbers detailed in Block 1
☐
Revoke current Patent Electronic System account
☐
Other – Describe in Detail:
Block 4 – Signature (Required)
I have read and understand the Subscriber Agreement (as listed on www.uspto.gov/ebc) and my signature on this document, by hand, is my
agreement to abide by the Agreement and the rules and policies of the USPTO regarding the Agreement.
I certify that the information, statements and representations pr ovided by me on this form are true and accurate to the best of my
knowledge. I understand that a willfully false certification is a criminal offense and is punishable by law (18 U.S.C. 1001).
Signature Required (Requestor from Block 2) Date (mm/dd/yyyy)
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