Invention/Work Disclosure Form

Inventors:

Inventor or Author 1:

Name:

Citizenship:

Campus:

Department:

College:

Email:

Phone:

Home Address (required by the USPTO for submission of patent applications):

Street Address

Street Address Line 2

CityState

Zip Code

Inventor or Author 2:

Name:

Citizenship:

Campus:

Department:

College:

Email:

Phone:

Home Address (required by the USPTO for submission of patent applications):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Inventor or Author 3:

Name:

Citizenship:

Campus:

Department:

College:

Email:

Phone:

Home Address (required by the USPTO for submission of patent applications):

Street Address

Street Address Line 2

CityState

Zip Code

Inventor or Author 4:

Name:

Citizenship:

Campus:

Department:

College:

Email:

Phone:

Home Address (required by the USPTO for submission of patent applications):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Inventor or Author 5:

Name:

Citizenship:

Campus:

Department:

College:

Email:

Phone:

Home Address (required by the USPTO for submission of patent applications):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Inventor or Author 6:

Name:

Citizenship:

Campus:

Department:

College:

Email:

Phone:

Home Address (required by the USPTO for submission of patent applications):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Inventor or Author 7:

Name:

Citizenship:

Campus:

Department:

College:

Email:

Phone:

Home Address (required by the USPTO for submission of patent applications):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Inventor or Author 8:

Name:

Citizenship:

Campus:

Department:

College:

Email:

Phone:

Home Address (required by the USPTO for submission of patent applications):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Inventor or Author 9:

Name:

Citizenship:

Campus:

Department:

College:

Email:

Phone:

Home Address (required by the USPTO for submission of patent applications):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Inventor or Author 10:

Name:

Citizenship:

Campus:

Department:

College:

Email:

Phone:

Home Address (required by the USPTO for submission of patent applications):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Invention/Work

Descriptive title of the invention/work:

Did the invention/work arise as a result of your duties or through the use by any personnel. including a University employee, or University resources such as facilities, equipment, or funds under the control of or administered by the University?

If yes, explain the resources:

Did this invention/work arise in the performance of work under a government contract/grant or sponsored research from a company?

If yes, what is the government agency/company name and contract/grant number:

Has this invention/work been published, presented or discussed publicly?

If yes, describe or provide citations/dates:

Are you aware of any closely related patents, copyrights, technical articles or publications, and competitive devices?

If yes, describe and provide citations, patent numbers, product website, etc.:

Describe the construction and operation of your invention/work, the practical problem your invention/work solves, the disadvantages of any current technology and the advantages of your invention/work:

Upload any draft manuscript, grant proposal, or other written document that describes your invention/work:

Upload a File

Files must be less than 100 MB