Form PTO 451 PTO 451 Pro Bono Client Intake Form

Client Intake Form
PTO 451 (Rev.4/20)
Approved for use through XX/XX/XXXX. 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

Client Intake Form for Pro Bono Regional Programs
What is your race?
o

African
American/Black

o
o

White
American Indian or
Alaska Native
Asian Pacific Islander
or Native Hawaiian

o
o

Prefer not to say

What is your gender?
o
o
o

Male
Female
Prefer not to say

Are you a Veteran?
o
o
o

Yes
No
Prefer not to say

Are you of Hispanic, Latino,
or Spanish Origin?
o
o
o

Yes
No
Prefer not to say

The collection of information in this section is requested by all Pro Bono applicants. The four questions are estimated to take 1
minute to complete. Time will vary depending upon the individual case. Any comments on the amount of time required to complete this
form and/or suggestions for reducing this burden, should be sent to the Chief Administration Officer, U.S. Patent and Trademark Office,
U.S. Department of Commerce, P.O. Box 1450, Alexandria, VA 22313-1450.

Client Intake Form

Note for OMB review: This information is being requested from Pro Bono participants through the regional
programs that are supported by USPTO. The aforementioned three questions are being sponsored by USPTO,
but is usually made available to the participants as a part of a larger registration information packet provided by
the regional programs. That larger registration packet is managed by the regional programs and the components
of the packet may vary depending upon the needs of that particular program/location.
Below is an example of how the client intake form, sponsored by USPTO, could appear as integrated into the
larger registration packet which includes regional registration information. Regional programs may include the
answer options as drop down selections, as seen in the example.

Solo Inventor Application

Page 1 of 3

Example of Pro Bono Program Application with embedded Client Intake Form

Solo Inventor Application for Pro Bono Program
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Page 1
I am applying on behalf of: *
Myself (solo inventor)
An Organization/Business
Personal Information
Salutation
Please select...



First Name *
John

A Nonprofit

Last Name *
Smith

Phone *

Personal Email *

(555) 555-5555

test.com

Address Line 1 *
111 home place
Address Line 2

City *
Atlanta
Postal Code *
21136

State *



Georgia

County *
Banks

How did you hear about our program?
Referred through Federal Circuit Bar
Georgia PATENTS Website
Other



Solo Inventor Application

Page 2 of 3

Client Intake Form
PTO 451 (Rev.4/20)
Approved for use through XX/XX/XXXX. 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

To aid us in applying for grants, we ask that you answer the following Demographic
Data questions.
This information is kept in confidence and only used in the aggregate.

What is your race?

African American/Black 

What is your gender?
Male


Are you a Veteran?
Yes
No

Are you of Hispanic, Latino, or Spanish Origin?
Yes 

The collection of information in this section is requested by all Pro Bono applicants. The four questions are estimated to take 1
minute to complete. Time will vary depending upon the individual case. Any comments on the amount of time required to complete this
form and/or suggestions for reducing this burden, should be sent to the Chief Administration Officer, U.S. Patent and Trademark Office,
U.S. Department of Commerce, P.O. Box 1450, Alexandria, VA 22313-1450.

Financial Information
Do you have a total household income of less than 300% of the poverty rate? *
Yes
No
This field is required.
Inventor Information
Are you the inventor to be listed on the patent? *
Yes
No
How many inventors will be listed on the patent? *
1
2
3
4
Have you been listed as an inventor on any other patent/pending application (other
than a provisional covering the present invention)? *
Yes
No
How have you satisfied the mandatory training requirement? *
Attended a Patent 101
Completed the USPTO
I have not satisfied the
Seminar
Online Training
requirement

Solo Inventor Application

Page 3 of 3

If you completed the online training, you will need to bring/send a copy of the
confirmation to the intake for verification.
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Contact Information