Volunteer Patent Pro Bono Application
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First Name *
Middle Name
Last Name *
Preferred Pronouns *
Race  *
Birthdate *
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Home Address *
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State *
Postal Code *
Law Firm/Organization
Title (Partner, Associate, Of Counsel, Patent Agent etc.)
Select State of Org / Practice *
City of Practice *
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I am licensed to practice law (specify states(s)) 
Law School
Law School Graduation Year
I am registered to practice with the USPTO *
Lawyer or Patent Agent Registration Number *
I have handled at least three (3) patent applications
 *
When did you pass the Patent Registration Exam?
Do you have Malpractice insurance *
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Malpractice insurance #
Practice areas that I am willing to work on (select all that apply) *
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Billable hourly rate
Share the language(s) other than English that you would be comfortable conversing in with a client
How did you hear about us?  *
Please provide any additional information you would like us to know about you.
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