TALA INDIVIDUAL PATENT MEMBERSHIP APPLICATION
This form is only for new members to TALA’s patent pro bono program for inventors. If you are an artist, please use our artists
new
and
renewal
forms.
Program Eligibility Information
I have read and agree to the
program guidelines
Please select...
I have read and agree to the program guidelines
Filing date of the provisional application for your invention (leave blank if not applicable)
Please upload your Certificate of Completion for the USPTO Pro Bono Program Training course
Financial Information
Please note that applications cannot be considered without the following information:
What is your household adjusted gross income based on last year’s federal tax return (line 7 on Form 1040)?
What is your approximate household income to date for the current year?
What is your Household size?
Number of Adults
Number of Children
What is your gross monthly household income?
Income Eligibility Calculation
What do you rely on as sources of household income? (Choose all that apply)
Self employment
Full-time job
Part-time job
Spouse/partner income
Savings/investment
Child support/alimony
Pension/Retirement
Disability Insurance
Need-based public assistance (ex. SSI, SNAP, TANF, etc.)
Other (please describe)
Other sources of household income (please describe)
I am aware of the income limit of this program which is
300% of the federal poverty level
provided by the United States Department of Health and Human Services.
I am aware that in order to receive services I may be required to provide proof of income in the form of a tax return or other means.
Member Information
First Name
Middle Name
Last Name
Suffix
Please select...
Jr.
Sr.
II
III
Professional Suffix
Please select...
CPA
Esq.
JD
PhD
Email
Phone
Residence Address
City
State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
Spouse Name
Business Name
Year Established or Acquired
Website
How did you hear about TALA?
Please select...
Attended a TALA event
TALA website, Internet Search
Heard about it from a colleague/ family member / friend
Heard about it from a TALA Member
Heard about it from a TALA Board Member, Volunteer Attorney/CPA
Heard about it from a TALA Staff Member
Newspaper advertisement
Other website
Picked up a brochure
Saw a media story about TALA
Social media link via Facebook, Twitter, LinkedIn, etc
Web banner or online advertisement
Other (Please describe)
How did you hear about TALA? (please describe)
The information below is not required and you may select “Prefer not to answer”. Eligibility for TALA programs is not affected by your answers to these questions. The answers to the following five questions will only be used in the aggregate for reporting purposes.
PTO 450 (Rev.4/20) Approved for use through 06/30/2023. OMB 0651-0082 U.S. Patent and Trademark Office; U.S. DEPARTMENT OF COMMERCE
Under the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB Control Number. Response to this information collection is voluntary; however, the data collected from this survey will be used to evaluate and publicize the Patent Pro Bono Program. Any comments on the amount of time you require to complete this survey and/or suggestions for reducing this burden, should be sent to the Chief Administrative Officer, United States Patent and Trademark Office P.O. Box 1450, Alexandria, VA 22313-1450.
What is your race/ethnicity?
Please select...
Asian, Pacific Islander, or Native Hawaiian
Black/African American
Hispanic/Latino
Middle Eastern, Arab or North African
Multi Race or Ethnicity
White
Native American or Alaska Native
Other
Prefer not to say
Are you of Hispanic/Latino/Spanish heritage?
Please select...
Yes
No
Prefer not to say
Your race/ethnicity, if not listed above:
What is your gender?
Please select...
Female
Male
Non-Binary
Prefer not to say
Do you self-identify as a member of the LGBTQIA community?
Please select...
Yes
No
Prefer not to say
Are you a veteran?
Please select...
Yes
No
Prefer not to say
Invention Details
In filling out the information below, do not include proprietary or confidential information about your invention.
Who was your employer at the time the invention was conceived?
Please enter N/A if you were not employed
Was your invention conceived in the course of your employment?
Yes
No
Please select "No" if you were not employed
Have you completed a prior art or an internet search on your invention?
Yes
No
Category of your Invention
Please select...
Electrical
Mechanical
Chemical
Short Title of your Invention
Subject matter of your invention (ex. “improved motor for lapidary wheel”)
What is the problem to be solved by the invention, and how does the invention provide a solution?
Payment Information
Your card will be charged $100 for the TALA membership fee.
Name on Card
Card Number
MM
YY
Code
Contact Information