Premier IP Protection, LLC
"Our Law Firm Protects Your Creativity"
Premier IP Protection, LLC
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Licensing Disclosure Form

This form should be used if you want us to consider a matter involving licensing of a patent, copyright, trademark or 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 license you want to grant to or that you want to accept from another (for example, chemical formula for testing water chlorine level, apparatus for filtering waste water, or process for making gasoline, etc.):
II.
Do you want only general advice regarding granting and accepting licenses rather than advice regarding a specific set of facts?
III.
Does this matter involve granting a specific license to another?
IV.
Does this matter involve accepting a specific license from another?
V.
To the best of your knowledge, does the subject matter of the license concern a patent?
VI.
To the best of your knowledge, does the subject matter of the license concern a trademark?
VII.
To the best of your knowledge, does the subject matter of the license concern a copyright?
VIII.
To the best of your knowledge, does the subject matter of the license concern a trade secret?

Our Assurance of Confidentiality
Premier IP Protection, LLC hereby agrees that licensing information provided herein by the individual(s) named in this Licensing 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 Licensing 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 Licensing 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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