D-1-b Application Form for Consultation by 9vaq65C


									                     Application Form for Consultation
                                                  Japan Intellectual Property Arbitration Center


  Occupation        1. Employed 2. Self-Employed 3. Professional
                    4. Others (                       )
  Address or        〒       -
   Place of
     Tel                    (               )                 Fax             (             )

E-mail Address

 Opponent in        ※ In cases where there are descriptions in this column, a patent attorney and an
 Dispute, etc.      attorney-at-law who have no interest with the opponent in dispute, etc. shall be appointed.

   Summary          1. Patent 2. Utility Mode 3. Design 4. Trademark 5. Unfair Competition Prevention Law
      of            6. Employee Invention    7. Domain Name   8. Contract
  Consultation      9. Others (                                                   )

                    (Please select consultation classification from 1~9 above, and specifically describe the
                    summary of consultation. It can also be provided as an attachment hereto.)

 Preference for     ※ Please note that if you request the creation and delivery of a consulting record (pay),
   creation of      it will take about two weeks to receive it.
     record                        Request / Not Request / Not yet Determined
 Preference for                   Tokyo Head Office / Kansai Branch / Nagoya Branch
   Location                              / Hokkaido Branch / Kyushu Branch
 Preference for
  Number of          One consultant (10,500 yen / hour) / Two Consultants (18,900 / hour)
  Preference for    First Choice            Date:                Hour: from           to
 Date and Hour      Second Choice           Date:                Hour: from           to
(Please designate   Third Choice            Date:                Hour: from           to
   up to three      ※Time available for consultation 10:00~16:00 on weekdays
     choices)       ※Please make your choices in intervals of two business days
How did you learn 1. Home Page 2. Japan Federation of Bar Associations
of this Center?   3. Japan Patent Attorneys Association
                 4. Government and other Public Offices
                 5. Introduction by Intellectual Property Referral Center
                 6. Introduction by Japan Legal Support Center 7. Introduction by other
                 8. Introduction by a friend 9. others (                          )

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