Entrepreneurial Legal Services Clinic & Intellectual Property Clinic Application

Entrepreneurial Legal Services Clinic & Intellectual Property Clinic Application

To be considered for acceptance as a client, you must complete this form and return it to the Clinic. Acceptance as a client of the Clinic is not guaranteed, and is ultimately based upon available resources and time to provide services, absence of conflicts of interest, financial need of the client, and educational value for our students. Applicants for services are hereby notified that the University of Missouri-Kansas City and the Clinic do not discriminate on the basis of race, color, creed, sex, sexual orientation, age, national origin, disability or Vietnam era veterans' status in admission or access to, or treatment or employment in, its programs and activities.
Name*

First NameLast Name
Previous Name/Maiden Name Used*
Age*
Date of Birth*
Company Name (If Applicable)

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
By providing your email address you are giving the Entrepreneurial Legal Services Clinic express permission to contact you via email with matters regarding your business and to contact you regarding other information that may be of interest to you. If you do not want the Entrepreneurial Legal Services Clinic to contact you via email please check the applicable lines below:

I do not want the Entrepreneurial Legal Services Clinic to contact me via email regarding my business.I do not want the Entrepreneurial Legal Services Clinic to contact me via email regarding other information that may be of interest to me.
Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Primary Language*
Financial Information

Per your Adjusted Gross Income on your Personal 1040 Tax Return
Total Monthly Income*
Please include all wages, Social Security benefits, child support, unemployment, pensions, etc.
Total Monthly Expenses*
Please include mortgage or rent, child support paid, health insurance, day care, etc.
Total Federal Benefits Received Monthly*
Please include all SSI, TANF, SNAP, etc.
Household Income Last Year: *
Total Household Income Expected This Year: *
Main Income Source*
Total Monetary Assets: *
Please include total value of cash you have, money in bank, investments, IRAs, retirement accounts
Total Property Assets: *
Consider the value of all furniture, household furnishings, jewelry, tools, home or land you don't live in. If you sold all these items, how much would you expect to get for them all together?
Do you own a vehicle and what do you use it for:*

PersonalBusinessBothI do not have a vehicle
Capital For the Business: *
Currently Employed?*

YesNo
If "Yes" above, where?
Number of People Under 18 in the Household*
Number of Adults in the Household*
Demographic Information

(This information is collected for demographic purposes only; it is anonymous and does not affect your acceptance as a client.)
Race*
Gender*
Ethnicity*
Marital Status*
Highest Level of Education*
Veteran (including National Guard and Reserves)*
Disabled*

YesNo
Required for Conflicts Checks
Principals/Owners*
Affiliates/Board Members/Officers
List any person or company, if any, who may have a claim against you or your business:
Are you currently a student at UMKC or any University of Missouri Systems Campus?*

YesNo
Are you an E-Scholar?*

YesNo
Do you currently have or expect to have any contracts, employment, or otherbusiness relationship with the University of Missouri-Kansas City or any other campus,office or operation of the University of Missouri System?*

YesNo
Are you a US Citizen or Resident Alien?*

YesNo
If "No" above, what is your immigration status?
Briefly state your legal question or problem/type of legal advice sought:*
Have you formed a business entity?*

Sole ProprietorPartnershipCorporationLimited Liability CompanyNon-Profit Corporation
If "Other" above, please describe.
Please list any deadlines under which you are operating (court dates, etc. if any).*
Briefly state your business plan if you are seeking legal services relating to a start-up company/entity formation).*
I hereby state the above information is true to the best of my knowledge, and give permission to the Entrepreneurial Legal Services Clinic and Intellectual Property Clinic to check for potential conflicts of interests between myself and affiliates, and with current and former clients of the Clinic, clients of firms at which students may be working, UMKC ,and the University of Missouri. I further confirm that I understand that work in the Entrepreneurial Legal Services Clinic and Intellectual Property Clinic is performed by law students under the supervision of licensed attorneys and therefore I may experience a delay due to the work being completed by said students.
Please verify that you are human*
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Entrepreneurial Legal Services Clinic & Intellectual Property Clinic Application

Financial Information

Demographic Information

Required for Conflicts Checks