Please complete this form if you are interested in becoming a volunteer patent attorney with the Ohio Patent Pro Bono Program . (* = Required Field) First Name* Last Name* Street City State/Province --None-- OH MI Zip Country US Email* Law Firm/Company* Office Phone* What languages do you speak fluently? Are you a CIPLA member? --None--Yes No Are you a patent attorney? --None-- Yes No USPTO # Where are you licensed to practice? --None-- Kentucky Ohio State bar number State bar admission date What kind of technology do you work with? What kind of technology do you NOT work with? What application type would you prefer to receive? [Hold down “Ctrl” to select more than one option.] Consumer Products Electronics Life Sciences Mechanical Other When will you be available to start reviewing pro bono referrals?