ProBoPat Volunteer Interest Form
Contact/Firm Information
First Name
Middle Initial
Last Name
Direct Phone
Direct Email
Firm/Company Name
Firm Street Address
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Does your firm have a Pro Bono Coordinator?
Yes
No
Pro Bono Coordinator First Name
Pro Bono Coordinator Last Name
Email of Pro Bono Coordinator
Will you be performing this work as a member of the Association of Corporate Counsel - Colorado?
Yes
No
May we identify you (and your firm affiliation) on our website or blog as being a volunteer?
Yes
No
Practice Information
In what areas do you practice patent prosecution? (Check all that apply)
Mechanical
Electrical
Chemical
Business Methods
Software
Biotech
Other
Other patent prosecution area
Are you registered and in good standing to practice before the USPTO?
Yes
No
USPTO Registration Number:
I am a
Patent Attorney
Patent Agent
Malpractice Insurance Certification
Will your pro bono work representing clients in patent matters be covered at all times by a malpractice insurance policy?
Yes
No
ACC Colorado members may wish to confirm coverage at
http://www.acc.com/chapters-networks/colorado/get-involved-pro-bono
.
Are you able to make this certification on behalf of all patent professionals at your law firm or patent department?
Yes
No
Volunteer Acknowledgements
By writing my full name in the box below, I confirm that the information provided in this form is true and complete to the best of my knowledge.
Full Name
Today's Date
Contact Information
Mi Casa Resource Center
345 S Grove St, Denver, CO 80219
Main Line: (303) 573-1302
Business Hours: Mon-Thurs 8 a.m. - 6 p.m. | Fridays 8 a.m. - 4:30 p.m.
http://www.micasaresourcecenter.org/
|
info@MiCasaResourceCenter.org