IP Clinic Intake Form

Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are you currently located in the Commonwealth of Pennsylvania?*

Phone*

Alternate Phone

Email Address*

Is your annual household income below the current USPTO Micro Entity Status Gross Income Limit (i.e $216,109 as of March 2021)?*

I am seeking service as*

Has a legal entity been formed?*

If a legal entity has been formed, what is the legal entity's name?

I am part of:*

Are you part of the Penn State or LaunchBox and Innovation Hub Network Community?*

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

If you've been a client, which clinic or program were you a client at?

Have you received any funding for this matter?*

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

Do you have any patent applications on file?*

Please identify your legal needs

Brief description of the nature of your business and legal needs.*

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