Volunteer Patent Pro Bono Application
Salutation
Please Select
Ms.
Mrs.
Mr.
Mx.
Prof.
Dr.
First Name
*
Middle Name
Last Name
*
Pronouns
*
Please Select
HeHim
SheHer
TheyThem
HeThey
SheThey
Not Listed
Gender
*
Please Select
Female
Male
Transgender Female
Transgender Male
Gender Variant or NonConforming
Not Listed
Prefer Not to Answer
Race
*
Please Select
Asian or Pacific Islander
African American or Black, Not of Hispanic Origin
Hispanic
Multi-racial
American Indian or Alaska Native
White - not of hispanic origin
Other
Birthdate
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Law Firm / Organization Name
*
Title (Partner, Associate, Of Counsel, Patent Agent etc.)
*
Law firm/organization address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where are you barred?
Maryland
Washington D.C.
Virginia
Other State
Federal Court (District)
Are you currently a law student?
yes
no
Law School
Law School Graduation Year
I am registered to practice with the USPTO
*
Yes
No
Lawyer or Patent Agency Registration Number
*
I have handled at least (3) patent applications
*
Yes
No
When did you pass the Patent Registration Exam?
Do you have malpractice Insurance
*
Yes
No
Carrier Name
Malpractice Insurance Policy #
Practice areas that I am willing to work on (select all that apply)
Design
Software
Mechanical
Chemical
Bio/Life Sciences
Other
Billable Hourly Rate
*
How did you hear about us?
*
Please Select
Word of Mouth
Google Search
Social Media
Other
Please share how you heard of MDVLA.
Share the language(s) other than English that you would be comfortable conversing in with a client.
Spanish
Chinese Incl. Mandarin Cantonese
French Incl. Cajun
Other
Please provide any additional information you would like us to know about you.
Lead Source
Please Select
Patent Volunteer App
Lead Status
Open - Not Contacted
Lead Record Type
Volunteer Lead
OwnerId
Submit
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