Reset Form
Print Form
BUSINESS & COMMUNITY LAW CLINIC
PATENT CLIENT APPLICATION
Please Note: This application should only be used for the purposes of applying to the Patent Clinic.
All other applications should use the For-Profit Client Application or Non-Profit Client Application
available on our website. Feel free to attach additional sheets if complete answers are not possible in
the space provided.
PART I: GENERAL INFORMATION ABOUT YOU
1. Name of Inventor/Contact Person:
Position/Title:
Address:
City:
State:
Work Phone:
Home Phone:
E-mail:
Citizen:
What is the best time to contact this person?
Zip Code:
U.S.
Other (specify)
Morning
Lunch Hour
Evening
Other:
Name of Additional Contact Person(s), if any:
Relationship to Inventor:
Address:
City:
State:
Zip Code:
Work Phone:
Home Phone:
E-mail:
What is the best time to contact this person?
Morning
Lunch Hour
Evening
Other:
Please attach a list of any additional partners, and/or any other contact persons.
2. How did you hear about the Business & Community Law Clinic or Patent Procurement Law Clinic?
Website
Facebook
Twitter
Bizdom
Automation Alley
Friend/Relative
OU INCubator
Organization:
TechTown
Macomb-OU INCubator
Other (Specify)
Page 1 of 7
PART II: GENERAL ORGANIZATION INFORMATION
(PLEASE PROVIDE ONLY GENERAL NON-CONFIDENTIAL INFORMATION AT THIS
STAGE OF EVALUATION)
1. Please describe in general NON-CONFIDENTIAL terms your invention (this information will be
used to help select clinic clients with inventions that complement the educational and/or experience
background of incoming law students for the next school semester):
2. Are you able to describe your invention in such a way that an ordinary person could make or use it?
Yes
No
If no, how soon do you anticipate being able to?
3. Have you ever used your invention publicly?
Yes
No
If yes, please describe the date and circumstances of any public use in more
detail.
4. Have you ever offered the invention for sale, either to the public or to a business?
Yes
No
If yes, please describe the date and circumstances of any offer for sale in more detail.
5. Have you ever publicly disclosed your invention (in a printed publication, news story, website, trade
show, etc.)?
Yes
No
If yes, please describe the date and circumstances of any publication or public disclosure of the
invention in more detail.
Page 2 of 7
6. Do you have any previous experience with intellectual property?
Yes
No
If yes, please explain your experience in more detail.
PART III: GENERAL INFORMATION ABOUT YOUR BUSINESS & FINANCES
1. Do you have a business set up related to this invention?
Yes
No
If no, do you intend to set one up?
Yes
No
If yes (to either question above), please explain in more detail.
2. Have you or your company entered into any contracts that relate to this invention (e.g. licenses,
funding/investment agreements, vendor agreements or leases)?
Yes
No
If yes, please describe the date and circumstances in more detail.
3. Do you anticipate collaborating with other individuals or businesses not already named relating to
this invention?
Yes
No
If yes, please explain in more detail.
Page 3 of 7
PART IV: GENERAL FINANCIAL INFORMATION AND FAMILY INFORMATION
(PROVIDE THIS INFORMATION FOR EACH OWNER)
Please provide the names of your board members that also serve as the officers of your corporation.
Michigan law requires the officer positions of President, Secretary and Treasurer.
1. What is your personal Gross Annual Income?
$0-25,000
$25,000 - 50,000
$100,000 - 150,000
$50,000 - 75,000
$75,000 - 100,000
$150,000+
2. What is the source of your income?
3. Do you have a spouse or significant other who contributes financially to your household?
Yes
No
If yes, what is your spouse's or significant other's personal Gross Annual Income?
$0-25,000
$25,000 - 50,000
$100,000 - 150,000
$50,000 - 75,000
$75,000 - 100,000
$150,000+
4. Do you have any assets? (e.g., real estate [including personal residence], cash, checking account,
savings account, stocks, other investments)
Yes
No
If yes, what assets do you have and what is the approximate value of your assets?
Type of Asset
Approximate Value
Page 4 of 7
5. Are you being financed in part or in full by a source other than yourself?
Yes
No
If yes, by whom? (E.g., family members, friends, grants) Please describe.
6. Have you applied for any loans to finance your invention?
Yes
No
Do you plan on applying for loans in the near future?
Yes
No
If yes to either question, please describe dates and circumstances in more detail.
7. Are you planning to take on any new investors?
Yes
No
If yes, please explain.
8. Can you afford to pay for filing fees you may be required to pay in connection with the legal
assistance you need?
Yes
No
9. Who are the family members who live with you and describe the family members?
Name
Relationship to Inventor
Page 5 of 7
PART V: LEGAL REPRESENTATION
1
Please explain why you cannot afford to pay for legal services offered by attorneys in the private bar.
2. Are you willing to be represented by second and/or third year law students who will be closely
supervised by licensed attorneys who are registered to practice before the Patent and Trademark
Office?
Yes
No
3. Has a lawyer ever worked with you on this matter?
Yes
No
If yes, please answer the following
a. What is the lawyer's name?
Full Address:
Telephone Number:
b. Why is she/he no longer representing you or your business in this matter?
c. Does she/he continue to work with you regarding other matters?
Yes
No
d. What work did she/he perform?
e. Did you pay for any of the legal services described above?
Yes
No
4. If the need for Clinic services relates to responding to an office action for an existing patent
application, please provide the following information regarding the application:
Filing date:
Serial No.:
Utility Patent Application or
Design Patent Application
Mailing date of the Office Action from the USPTO:
5. If the need for Clinic services relates to an application that has been published, please provide:
Publication No.:
Date of Publication:
6. If the need for Clinic services relates to an existing provisional application, please provide:
Filing Date:
7. How many U.S. utility/design patent applications have you previously applied for?
How many of these applications were through an employer with an obligation to
assign to the employer?
Page 6 of 7
AUTHORIZATION TO RELEASE INFORMATION
Application Information: I hereby authorize the Business & Community Law Clinic and the Patent
Procurement Law Clinic at Wayne State University Law School (collectively referred to herein as the
"Clinic") to verify and make copies of any and all information provided in this application in the course
of determining my eligibility for receiving the Clinic's legal assistance.
I hereby authorize the Clinic to use my name and/or my business name, as well as any public information
regarding my invention (i.e. published patent application, issued patent, trademark and/or logo) in any
marketing materials made to promote and/or describe the services of the Clinic.
I hereby authorize and consent to the use of e-mail by the Clinic to communicate with me regarding
matters relating to this application and matters relating to my legal representation by the Clinic (if
selected as a Clinic client).
I acknowledge and agree that the Clinic will NOT be responsible for docketing and/or arranging payment
of maintenance fees associated with any patent issued by the United States Patent Office. I acknowledge
and agree that timely payment of any maintenance fee is my responsibility. I acknowledge and agree
that I am responsible for payment of any out of pocket expenses (governmental filing fees, formal patent
drawing preparation fees, etc.) associated with preparation and prosecution of any patent application.
Release: I hereby release any person or entity complying with this Authorization from any and all claims
relating to the disclosure of any such information and documents, and relating to the docketing and/or
timely payment of maintenance fees for any issued patent.
I hereby certify that all of the information in this application is true, correct and complete and that I am
authorized by the above business to submit this application to the Clinic. I further agree that the business
will notify the Clinic in the event of any changes to this information and understand and agree that the
Clinic has the right, at its sole discretion, to reject any applicant/business, or withdraw from representing
the above applicant/business for any reason, including by way of example and not limitation if the
information submitted on the application is inaccurate or if the applicant/business achieves sufficient
financial strength and stability to no longer qualify for pro bono services through the Clinic. Moreover, I
acknowledge that the Clinic has the right, at its sole discretion, to select or not select my business to be a
client of the Clinic.
Signature:
Print Name:
Title:
Date:
Please submit this application by mail, fax or e-mail to:
Business & Community Law Clinic
Patent Procurement Law Clinic
Wayne State University Law School
471 W. Palmer St., Detroit, MI 48202
Phone: 313-577-9429
Fax: 313-577-9379
E-mail: patentclinic@wayne.edu
Page 7 of 7