Fillable Credit Card Payment Form (Page 3 of 3) in pdf

Credit Card Payment Form Page 3

Download a blank fillable Credit Card Payment Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Credit Card Payment Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

PTO-2038 (05-2012)

Approved for use through 11/30/2014. OMB 0651-0043

United States Patent and Trademark Office; U.S. DEPARTMENT OF COMMERCE

Under the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

displays a valid OMB control number.

Credit Card Payment Form

(Do not submit this form electronically via EFS-Web)

Please Read Instructions before Completing this Form

Credit Card Information



Credit Card Type:

Visa

MasterCard

American Express

Discover

Credit Card Account #:

Credit Card Expiration Date (mm/yyyy):

Name as it Appears on Credit Card:

Payment Amount (US Dollars): $

Cardholder Signature:

Date

(mm/dd/yyyy)

Refund Policy: The USPTO may refund a fee paid by mistake or in excess of that required. A change of purpose after the payment of a

fee will not entitle a party to a refund of such fee. The USPTO will not refund amounts of $25.00 or less unless a refund is specifically

requested and will not notify the payor of such amounts (37 CFR 1.26). Refund of a fee paid by credit card will be issued as a credit to the

credit card account to which the fee was charged.

Maximum Daily Limit: Effective June 30, 2012, the daily limit per credit card account will decrease from $99,999.99 to $49,999.99, and

the daily limit for debit cards will be eliminated.

Credit Card Billing Address

Street Address 1:

Street Address 2:

City:

State/Province:

Zip/Postal Code:

Country:

Daytime Phone #:

Fax #:

Request and Payment Information

Description of Request and Payment Information:



Patent Fee

Patent Maintenance Fee

Trademark Fee

Other Fee

Application No.

IDON Customer No.

Patent No.

Registration No.

Attorney Docket No.

Identify or Describe Mark

If the cardholder includes a credit card number on any form or document other than the Credit Card Payment Form or

submits this form electronically via EFS-Web, the United States Patent and Trademark Office will not be liable in the

event that the credit card number becomes public knowledge.

Credit Card Payment Form Page 3

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