(Information on this form will be used for determining conflicts of interest, preparing a patent application, and/or preparing formal filing paperwork.)

 

I.  Client Information

Legal name of company or person to own patent: __________________________________________

Home #: ______________________ Work #: _________________________ Cell #: _____________________

Email: ____________________________________ Website: __________________________________________

Street Address: _______________________________________________________________________________

________________________________________________________________________________________________

Mailing Address: ______________________________________________________________________________

________________________________________________________________________________________________

Citizenship: ___________________________________

If the Company is a Corporation (or other type of business entity), the state of incorporation: ________

Persons who are authorized to sign on behalf of the company:

Name: __________________________________________ Title: _____________________________________

Name: __________________________________________ Title: _____________________________________

Name: __________________________________________ Title: _____________________________________

Does the company, investors in the company, or any licensees of the company have more than 500 employees (Y/N)? ______ Are there more than 50 employees(Y/N)? _____

Referred by: _______________________________________________________________

General Technology (e.g. software for a dry cleaning business, a medical device for use in brain surgery, an improvement to a "widget," a board game, a new type of furniture that you can sit on, a device used to solve the problem of "snoring"): ______________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

What type of protection (e.g. Provisional (please indicate with or without review), Nonprovisional (Utility), or Nonprovisional (Design)) you are interested in pursuing: ______________________________________________________

II.  Inventors

Please provide information for each anticipated inventor. For more information, please see Inventorship.

Inventor #1: ______________________________________________ Citizenship: _____________________

Home #: ______________________ Work #: _________________________ Cell #: _____________________

Fax #: ______________________ Email: ___________________________________________________________

Home Street Address: _______________________________________________________________________

City: __________________________________ State: ____________________ Zip: _______________________

Work or Mailing Address: ___________________________________________________________________

City: __________________________________ State: ____________________ Zip: _______________________

Inventor #2: ______________________________________________ Citizenship: _____________________

Home #: ______________________ Work #: _________________________ Cell #: _____________________

Fax #: ______________________ Email: ___________________________________________________________

Home Street Address: _______________________________________________________________________

City: __________________________________ State: ____________________ Zip: _______________________

Work or Mailing Address: ___________________________________________________________________

City: __________________________________ State: ____________________ Zip: _______________________

Inventor #3: ______________________________________________ Citizenship: _____________________

Home #: ______________________ Work #: _________________________ Cell #: _____________________

Fax #: ______________________ Email: ___________________________________________________________

Home Street Address: _______________________________________________________________________

City: __________________________________ State: ____________________ Zip: _______________________

Work or Mailing Address: ___________________________________________________________________

City: __________________________________ State: ____________________ Zip: _______________________

Please attach a separate sheet listing any other inventors.

Did anyone else suggest changes to the invention (Yes/No)? _______

If yes, please provide detailed information.

 

III. Officers, Owners, and High-Level Employees

Please provide information for each officer, owner, or high-level employee. Owners may include parent corporations, companies having an interest in the client, or investors.

Legal name: _________________________________________ Title/Interest: _________________________

Home #: ______________________ Work #: _________________________ Cell #: _____________________

Fax #: ______________________ Email: ___________________________________________________________

Home Street Address: _______________________________________________________________________

City: __________________________________ State: ____________________ Zip: _______________________

Work or Mailing Address: ___________________________________________________________________

City: __________________________________ State: ____________________ Zip: _______________________

Legal name: _________________________________________ Title/Interest: _________________________

Home #: ______________________ Work #: _________________________ Cell #: _____________________

Fax #: ______________________ Email: ___________________________________________________________

Home Street Address: _______________________________________________________________________

City: __________________________________ State: ____________________ Zip: _______________________

Work or Mailing Address: ___________________________________________________________________

City: __________________________________ State: ____________________ Zip: _______________________

Please attach a separate sheet listing any other owners, officers, and high-level employees.

 

IV.  Direct Competitors

Legal name: _________________________________________ Phone: ____________________________

Address and/or website: __________________________________________________________________

Description of competing device/method:  _______________________________________________

_____________________________________________________________________________________________

Legal name: _________________________________________ Phone: ____________________________

Address and/or website: __________________________________________________________________

Description of competing device/method:  _______________________________________________

_____________________________________________________________________________________________

Please attach a separate sheet listing any other direct competitors.

V.  Dates and Information:

A.1. Date the invention was conceived: ___________________

A.2. Did all the people involved in the conception and/or development sign non-disclosure or confidentiality agreements? _______ (Y/N)

A.3. Do you have a prototype? _______ (Y/N) If yes, what is the date the prototype was constructed? _______________

A.4. Has the prototype been used in public (even in your own home if guests could see it)? _______ (Y/N) If yes, on what date? _________________

B.1. Have you tested (experimental use) the invention? _______ (Y/N) If yes, please provide detailed information about (a) the nature/description of the test(s), (b) the results of the test(s), (c) who conducted the test(s), (d) the dates of the test(s), and (e) the location of the test(s).

B.2. Did all the people involved in or present at the testing sign non-disclosure or confidentiality agreements? _______ (Y/N)

B.3. Do you have documentation of the testing? _______ (Y/N) (If yes, please attach it.)

C.1. Have you disclosed your invention? _______ (Y/N) If yes, please list any confidential or nonconfidential disclosures including, but not limited to, publications (including on the Internet), offers to sell, public uses (even in your own home if others saw the invention and even if it was a “secret” public use in that someone seeing the invention would not know it was an invention), and/or oral descriptions.  For each disclosure, please provide:

• C.1.a.  To whom you disclosed your invention.
• C.1.b.  A description of the disclosure (e.g. type of disclosure, what was disclosed, to whom was the disclosure made).
• C.1.c.  The date of the disclosure.
• C.1.d.  Was the disclosure confidential?  If yes, please indicate how it was confidential (e.g. confidentiality agreement).

C.2. If you have not yet disclosed your invention, when do you plan to disclose it? ______________________

D.1. Have you previously filed any patent applications (including provisional patent applications) in the United States and/or any foreign countries? _______ (Y/N) If yes, please provide dates, details, and copies of all filings.

D.2. Are you interested in foreign protection if it is available? _______ (Y/N)

VI.  INVENTION DESCRIPTION

Providing the following information may help in the preparation of an application. Some questions may not be relevant to your invention. Some of the questions may be repetitive so you can refer to previous answers.

A.  Drawings: Provide figures that depict your invention; while dimensions are optional, they can be helpful (depending on the invention). You may also attach computer code, flowcharts, and/or photographs.

B.  Please suggest a descriptive title for your invention.

C.  Please briefly describe the general field of technology to which the invention relates. (For example, if your invention cures cancer, describe the cancer, how many people would be saved, general research trends, general problems encountered, etc.)

D.  Please describe specific prior art that is similar to or has aspects similar to your invention. You should attach known patents, brochures of possible competitors, websites, or other material that describes the prior art. For each prior art reference, you should provide (1) a description of the prior art, (2) the differences between your invention and the prior art, and (3) the advantages of your invention over the prior art.

E.  Please describe your invention. You should refer to drawings, charts, photos, computer algorithms/code, or any visual aids you can provide. You may want to include a list of vendor information and part numbers. The description should include your "best mode" and be sufficient to allow one skilled in the art to implement the invention without undue experimentation.

F.  Please describe the problem(s) your invention is meant to solve.  How does your invention solve these problems?

G.  Please describe how your invention is constructed and/or implemented.

H.  Please provide a description of how your invention is used.

I.  Please provide a description of the advantages and special results of the invention (e.g. test results).

J.  Please describe possible variations (alternative embodiments) of your invention.

K.  What features of your invention are you most interested in protecting? These features should not be present in any known devices/methods.