Conflict check

Questionnaire for Conflict Check/Engagement ：

Please fill in the information as completely as possible. Feel free to contact us if you need any clarifications or have any queries about this questionnaire.

A. Referrer’s Name

1. Referrer’s Name

B. Information about individual providing information on this questionnaire

1. Name

2. E-mail address

3. Phone number

4. Relationship with client to-be (e.g., President, CEO, self, etc.)

C. Client’s Name

1. Legal name of the corporation or person who is to be our client

2. Mailing address (Street number, City, State, and Zip Code)

3. Phone number; Fax number; website

4. Country of incorporation (if possible, please provide a copy of the Certificate of Incorporation)

A Copy of the Certificate of Incorporation

5. Number of employees

6. Nature of corporation (e.g. high tech, non-profit, educational or research)

7. Legal name of all Affiliates, Subsidiaries, Parent Company of corporation

D. Nature of Matter (Select ALL services sought)

1.Intellectual Property

Patent:

Filing

Prosecution

Searches

Trademark:

Filing

Prosecution

Searches

Copyright:

Filing

Legal Opinion:

Patentability

Infringement

Freedom of Operation

Dispute:

Patent

Trademark

Copyright

Others/General

Trade Secrets

2.Transactional

3.General

3.General

Searches

Commercialization

Due Diligence

All Other Matters (Please Describe)：

E. Invention and Inventors (For Patent Only)

1. Title of the Invention (Final or working title)

a) Technical Field (e.g. anticancer drug, purification of DNA, disease diagnosis, stem cells)

b) Invention (please provide key terms and/or a few sentences describing the invention)

(Note: key terms are those that one would search in order to find relevant prior art information about the invention, and are important for us to perform conflict check.)

c) Application Type e.g. utility, utility model, design (please also provide the application no. of any filed patent application in connection with this invention, if any)

2. Full legal names of ALL Inventors

a) List each name as it appears on passport with family name capitalized (e.g., SMITH, John M.)

b) Note the employer for each inventor; e.g., next to each name, add “(Employed by ________________)”.

c) Name of the entity that has the rights to the invention (e.g. Assignee).

F. Dispute

1. Nature of dispute

2. Issues raised by a third party

3. Opposing Parties or Potential Competitors

4. Any anticipated or initiated proceedings (including court actions, administrative proceedings, arbitration or mediation)

Payment

Questionnaire for Conflict Check/Engagement ：