Patent Intake Form Client contact information for engaging Clark & Bellamy’s patent prosecution legal services. Formal Name of the Client*The owner and contact person might differ. Identify the client here.Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address (Client)*The client will enter a separate address for the primary contact person or employee if different than the client.Entity Type (if applicable)Sole ProprietorshipLLCCorporation (for profit)Non-profit corporationOtherIf the client is a business, please select an entity type. Other Entity TypeState Organized (if LLC/Corporation, etc)Land Phone Number (Client)Mobile Phone Number (Client)Fax (Client)Contact Person is Same as the Owner?* Yes No CONTACT INFORMATION(IF DIFFERENT THAN THE CLIENT)Name of Contact PersonTitle of Contact PersonEmail Address (Contact)Land Phone Number (Contact)Mobile Phone Number (Contact)Street Address (Contact)Apartment, suite, etc (Contact)City, State, Zip (Contact)Invention InformationInventor(s) the same as* Owner named Contact Person Other An inventor is an individual who has contributed to the conception of one or more of the specific, inventive aspects of the invention as claimed in the patent application. An inventor may have contributed to the overall idea, the design, or a unique feature. It’s essential to list all individuals who have made such contributions. It’s not necessary for an inventor to have contributed to every claim of the patent application. If multiple individuals contributed, each person who has made a contribution to at least one claim should be listed as an inventor. Please add any additional inventors by clicking checking “other” to open a new list box.List Inventor(s), Address of Residence, CitizenshipPlease indicate if the owner or contact person is also an inventor.BRIEF DESCRIPTION OF THE INVENTION*Please provide a brief description the invention that you request Clark & Bellamy to provide patent prosecution services.This field is hidden when viewing the formAgreementAgreement*By clicking the Submit button below you electronically agree to Clark & Bellamy, P.C.’s website Terms of Use, Privacy Policy, and the Firm’s Patent Engagement Terms. Click to Consent CAPTCHA Δ