Penn State Law IP Clinic Intake Form

Name*

Previously used names*

Address*

City, State, Zip Code*

Phone*

Alternate Phone

Email Address*

Is your annual household income below the current USPTO Micro Entity Status Gross Income Limit (i.e $184,116 as of January 2019)?*

Yes
No

I am seeking service as*

Individual
Organization
Business
Prof. Weyer MGMT 426 Student

I am part of a business accelerator or co-working space*

Yes
No

Are you part of the Penn State Community*

Yes
No

Are you currently, or have you been a Client of any Penn State Law IP Clinics or Programs?*

Yes
No

Have you received any funding for this matter?*

Yes
No

Current Employer (if different from Business above)*

Former Employer (if applicable)*

Have you consulted any attorney(s) on this matter?*

Yes
No

Do you have any patent applications on file?*

Yes
No

Please identify your legal needs*

Patent
Trademark
Trade Secret
Copyright
General IP Advice

Other Legal Needs (explain)*

Brief description of the nature of your business and legal needs (if you are in MGMT 426, please indicate your questions and what patent application(s) you have been assigned):*

How did you learn about the Penn State Law IP Clinic? If you were referred to the IP IP Clinic, who referred you?*

Attachments or other materials? Please send to ipclinic@pennstatelaw.psu.edu.*

Yes
No

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