Patent Intake Form

On what date (specifically) did you conceive of your invention?
On what date (specifically) did you first disclose to anyone?
Inventor #1
Inventor Name #1*
Country of Citizenship
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
MM slash DD slash YYYY
E-mail*
Telephone Number*
Inventor #2
Inventor Name #2
Country of Citizenship
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
MM slash DD slash YYYY
E-mail
Telephone Number
Inventor #3
Inventor Name #3
Country of Citizenship
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
MM slash DD slash YYYY
E-mail
Telephone Number
Inventor #4
Inventor Name #4
Country of Citizenship
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
MM slash DD slash YYYY
E-mail
Telephone Number
If there is more than one inventor, who is the first named inventor?
Will the inventor(s) be assigning this patent to any other entity?*
If so, please provide the necessary information for this entity, i.e., name, address, type of entity (corporation, partnership, LLC, etc.)
Has any inventor(s) executed a confidentiality agreement or an employment agreement?*
If yes, please upload a copy
Max. file size: 32 MB.
And/Or if yes, please describe
Is there a prototype of the invention?*
Date Completed
MM slash DD slash YYYY
Has the invention ever been sold or offered for sale?*
Date
MM slash DD slash YYYY
Do you plan to publicly use or sell the invention soon?*
Are you aware of any information (e.g. prior patents or printed publications) that may materially affect the patentability of the described invention?*
If yes, please list all references:
Do you intend on filing the application in a foreign country?
Do you wish for the application to publish? (Patent applications automatically publish eighteen (18) months after filing.)
- Allow to Publish. This option must be selected for all applications where you intend to file in a foreign country.
- Request No Publication. This option may only be selected for an application where you intend never to file in a foreign country. (Fee applies for this option.)
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Inventor #1

Inventor #2

Inventor #3

Inventor #4

Do you wish for the application to publish? (Patent applications automatically publish eighteen (18) months after filing.)