Client Name:
Date:
Submitting Attorney:
Responsible Attorney:
Client Code:
Type of client (select one): Individual Corporation Company (LLC) Partnership (LLP) Other
Contact Name:
Email:
Address:
City: ST: ZIP:
Country:
Website:
Describe the Client's Business:
Number of employees:
List any affiliates or entities that are related in any manner to the client:
List the client's major competitors:
Nature of Representation: General Patent Application Patent Study Trademark Agreement Trade Secret Other
What technology is involved in this representation:
Do you know of any potential conflict? Yes No If yes, please explain.