Name First: _______________________ Last: _________________________
Address: ____________________________ City:_________________________
State: __________ Zip: __________ Hm Phone:____________________
Wk Phone:______________________ Date of Birth:___________________
Type of employment (if retired-last): _________________________________
INVENTION CATEGORY:
____ INDUSTRIAL, ____ CONSUMER, ____ NOVELTY, _____ TOY (GAME)
INVENTION STATUS:
_____ Idea Only, _____ Full Drawings Available, _____ Model, _____ Proto-Type
If currently marketed: Where _________________________________________
Volume of sales: __________________________ Retail Price: _____________
Have you applied for a patent? ___________ If yes when: _____________
Which type? _____________________________ Was it Issued?________
Are you the sole inventor? ______________________
Have you seen a product similar to yours on the market?_____________
Where? ________________________ How much was it selling for? _________
DO YOU WANT TO
____ Manufacture only, _____ Sell only, ____ Manufacture and Sell, _____ License
Do you have experience in manufacturing? _________ Sales? ________
I hereby submit this application and request for an appointment for a
personalized Walk Through, I understand the full cost of the program
is $175 + $10 registration fee to the Patent Office: Non-refundable
Deposit of $90 (payable to: The Dream Merchant) is enclosed. The
Balance ($85) to be paid upon my Walk Through: