KYIPA Membership Form

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Phone Number

Please enter a valid phone number.

4

Zip code* This field is required.

5

Company

6

What best describes your career status?* This field is required.

9

Have you ever filed for IP protection?

YESNO

11

What would you like to learn more about as a KYIPA member?

12

Opt In* This field is required.

Please check this box to join the Kentucky Intellectual Property Alliance (KYIPA). By doing so, you consent to us contacting you with the provided information. (Individual membership is free and you may opt out at any time. Please note, as part of your membership with KYIPA, your contact information will be provided to the USIPA.)

13

What best describes your race/ethnicity?

African American or Black

American Indian, Alaska Native, Indigenous, or First Nation

Arab or Middle Eastern

Asian or Asian American

Hispanic, Latina, or Latino

Multiracial or Biracial

White / Caucasian

Other

15

Do you identify as having a current or former military status (e.g. active duty, National Guard / Reserves, military spouse or dependent, veteran, etc.)?

YESNO

16

Do you identify as having a disability?

YESNO