Patent Intake Form

Applicant Contact Information

Note: This is a five-page intake form. To reduce the possibility of losing your inputs, please have the following information available prior to beginning the form: Contact information for the applicant and all inventors, complete invention disclosure and supporting files, dates of conception, prior filed patent applicantion numbers, & contact information for the assignee (if applicable) All information disclosed through this form will be treated as sensitive confidential information in accordance with Cerebral IP's Privacy Policy and Terms of Use.

Applicant First name

Applicant Last name

Your Business Position or Title

Business Phone Number (will be used on USPTO forms)

Business Email

Business Name (if applicable)

Business Website Address

Applicant Mailing Address

Business Mailing Address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Please identify your authority to file this patent application

I am the inventor or a joint inventor

Assignee

Legal Representative under 35 U.S.C. 117

Person to whom the inventor is obligated to assign

Person who shows sufficient proprietary interest