PTO/AIA/81 (07-12)
Approved for use through 03/31/2021. OMB 0651-0035
U.S. Patent and Trademark Office; U.S. DEPARTMENT OF COMMERCE
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Application Number
Filing Date
First Named Inventor
Art Unit
Examiner Name
NOTE: This form may be filed by pro se inventors (i.e., prosecuting the application without a registered patent
practitioner) who are identified as the Applicant in the above-identified application. For a Power of Attorney to one
or more registered patent practitioners, see form PTO/AIA/82.
I hereby revoke all previous powers of attorney given in the above-identified application.
I hereby appoint the following joint inventor(s) to prosecute the application identified above, and
to transact all business in the United States Patent and Trademark Office connected therewith:
Please recognize or change the correspondence address for the above-identified application to:
The address associated with Customer Number. (if applicable):
-To Request A Customer Number see form PTO/SB/124
Individual Name
I am the Inventor.
SIGNATURE of Inventor
: Signatures of all the inventors are required. Submit multiple forms if more than one
nature is re
see below*.
See 37 CFR 1.4 for signature
requirements and certifications.
*Total of forms are submitted.
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ADDRESS. SEND TO: Commissioner for Patents, P.O. Box 1450, Alexandria, VA 22313-1450.
If you need assistance in completing the form, call 1-800-PTO-9199 and select option 2.
Privacy Act Statement
The Privacy Act of 1974 (P.L. 93-579) requires that you be given certain information in connection
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