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Name
Title
Business Name
Business Website
Corporate/Main
Office Location
Phone
Fax
Address
Email

Company Annual
Sales Revenue

Customer Geographies

United States
Africa
Asia (China)
 Asia (Japan)
 Asia (Korea)
Asia (Taiwan)
 Asia (Other)

Australia
Canada
Central/South America
Europe (Eastern)
 Europe (Western)
Mexico
Other

Sales Interface

Interested in the
following type
of Intellectual
Property Rights

Purchase a Patent/Trademark
License with Exclusivity
 License without Exclusivity
 Other
If other, please explain

If licensing, please
check all that apply

Term Requested
0-3 years
4-5 years
 6-10 years
 10+ years

Will Offer
Annual License Fee
Royalty Per Unit
 Flat Fee 		Time Period to Close Deal
1-4 weeks
2-3 months
 4-6 months
 6+ months

Indicate Product(s)
of Interest