Conflict Clearance Form

 

Professional Responsibility requires conducting conflict clearances prior to client engagement to avoid engaging representation of clients with conflicting interests. By checking our client databases we can make sure we do not represent now, or in the past, a client with adverse interests to you.

Please fill in the conflict clearance form and submit it for approval, which typically takes one business day. Once cleared, we will contact you to agree upon terms of engagement.

Name:

Individual or Entity:

If Entity, type and state of organization:

 

Address:

 

Daytime Telephone:

Evening Telephone:

Facsimile Telephone:

E-mail:

Source (how did you hear of us?)

 

Name of person(s) of entities in dispute or in potential conflict if any:

 

Nature of services to be rendered: (please note all that pertain)

Patent - provide brief description of field of invention

Trademark: provide brief description of goods and services and actual mark in use or proposed to be used. If mark is in use in the course of business describe the use and the first use date.

Copyright

 

Domain Name

 

Other:

 

    By submitting this form you understand that the firm will use the information solely for the purpose of clearance for representation. This information will remain confidential. No legal advice will be rendered or is to be assumed until such time as an engagement agreement is executed outlining terms and strategy. (return this form by fax (703)979-2526 or e-mail to pla@bellatlantic.net , please note re: clearance form check)

 

 

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