Patent Intake Form

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On what date (specifically) did you conceive of your invention?

On what date (specifically) did you first disclose to anyone?

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Inventor Name #1*

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Address*

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Date of Birth*

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Inventor #2

Inventor Name #2

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Inventor #3

Inventor Name #3

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Inventor #4

Inventor Name #4

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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?*

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And/Or if yes, please describe

Is there a prototype of the invention?*

Date Completed

Has the invention ever been sold or offered for sale?*

Date

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.)

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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.)

Location

Melbourne, Florida