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Infringement Disclosure Form

This form should be used if you want us to consider a matter involving infringement of a patent, copyright, trademark or theft of a trade secret. You may fill-out this form and then return it to us via email by pressing the “submit” button at the end of this form. Alternatively, you may print-out this form, fill-in the requested information and return it to us by U.S. post office mail or facsimile.

* Required Field
*Your Name:
(first, middle, last)
Home Address:
Mailing Address:
City:
City:
State:
State:
Zip:
Zip:
*Home Phone:
Other Phone:
Fax:
*E-mail:
I.
*Briefly describe the subject matter of the infringement or theft of trade secret (for example, chemical formula for testing chlorine level in water, apparatus for filtering waste water, or process for making gasoline, etc.):
II.
Do you want only general advice regarding infringement rather than advice regarding a specific set of facts?
III.
Does this matter involve your alleged infringement of intellectual property rights of another (for example, your alleged infringement of another’s patent, copyright, or trademark)?
IV.
Does this matter involve alleged infringement of your intellectual property rights by another (for example, alleged infringement of your patent, copyright, or trademark)?
V.
To the best of your knowledge, does the subject matter of the infringement concern a patent?
VI.
To the best of your knowledge, does the subject matter of the infringement concern a trademark?
VII.
To the best of your knowledge, does the subject matter of the infringement concern a copyright?
VIII.
To the best of your knowledge, does this matter involve your alleged theft of a trade secret belonging to another?
IX.
To the best of your knowledge, does this matter involve alleged theft of a trade secret owned by you?

Our Assurance of Confidentiality
Premier IP Protection, LLC hereby agrees that licensing information provided herein by the individual(s) named in this Infringement Disclosure Form will not be revealed, used, disclosed, sold, or transferred without his or her express authorization, except if required by court order.

For Premier IP Protection, LLC:
Walter S. Stevens
Walter S. Stevens, Esq.
Manager Member

Submitter's Statement
By submitting this Infringement Disclosure Form and any other information pertaining thereto, I acknowledge that Premier IP Protection, LLC is accepting this information for review purposes only.  I understand that any comments that I receive based upon this review are based upon a limited analysis and is neither meant nor understood to be a conclusive legal opinion.  Further, I agree that Premier IP Protection, LLC cannot be held responsible for any recommendations based upon the review of the information herein and cannot be held responsible for the return of any submitted materials.  Even if no signature(s) for the individual(s) named hereinabove is/are included in the submitted form, I/we acknowledge that the submission of this Infringement Disclosure Form shall indicate my agreement to this Submitter’s Statement.

Signature**:
Date

** There is no need sign this form, if returning this form online. It will be assumed that the completed form is from the individual whose name appears above.

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