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Patent Invention Disclosure Form

This form should be used if you want to obtain a United States patent and/or a foreign patent. 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.
*Discuss the background of your invention (How is the function of your invention being done today by others?  What is being done today by others to address the problem solved by your invention.  In other words, what is the existing state of the art?): 
II.
Describe your invention (In a short paragraph or two, generally describe your invention including what it does and how it does it.  We will contact you later to obtain details regarding your invention.  Include sketches/drawings on a separate page, if applicable.  If sending sketches/drawings by email, the sketches/drawings should be in JPG, JPEG, GIF or Pdf format.  You may also send us sketches/drawings together with this completed form by facsimile.
  OR attach a file from your computer that contains your sketches/drawings, if any:
III.
Date your invention was conceived:
IV.
Date your invention was first reduced to practice (for example, date you constructed a working model of your invention):
V.
How is your invention an improvement over existing devices or processes (for example, your invention reduces costs, is more efficient, is easier to use, etc.):
VI.
Have you disclosed your invention to another person, either orally or in writing?  If so, when:
VII.
Have you disclosed your invention in a printed publication, such as in a newspaper article, magazine article, or sales brochure?  If so, when?
VIII.
Has your invention been shown or used in public?  If so, when?
IX.
Have you sold or offered your invention for sale as a product, either orally or in writing, such as at a trade show?  If so, when?
X.
Have you previously filed a patent application covering your invention, either in the United States or a foreign country?  If so, when?  If so, what is the patent application serial number?
XI.
Are there additional inventors?  If so, provide their names and contact information:
Name: Address: Phone:

Our Assurance of Confidentiality
Premier IP Protection, LLC hereby agrees that any information pertaining to invention(s), idea(s), and the like provided by the inventor(s) named in this Patent Invention Disclosure Form will not be revealed, used, disclosed, sold, or transferred without the express authorization of the inventor(s), except if required by court order.

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

Inventor's Statement
By submitting this Patent Invention Disclosure Form and any other information pertaining to this invention, idea, and the like, 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 Inventor(s) is/are included in the submitted form, I/we acknowledge that the submission of this Patent Invention Disclosure Form shall indicate my and any other inventors’ agreement to this Inventor’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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