ࡱ>  G1bjbj! ! CfCf5)rrrrr4h'vvvJ'L'L'L'L'L'L'$w)),Tp'rv|vvvp'rr,'vprrJ'vJ'l%h<&*n ^%6''0'%X},D>}, <&<&v},r&vvvvvvvp'p'Dvvv'vvvv},vvvvvvvvv 8: ɫͼ State University Invention Disclosure Form ɫͼ Statue University Intellectual Property Committee Office of the Provost 333 Wells Hall ɫͼ, KY 42071 IPC USE ONLYDate Received: Project ID:  Part A Inventions and Patent Disclosure Please complete all fields and return to the above address. If you have any questions, please call (270)809-3744. TitleTitle of Invention: MSU FOAPAL OR OSP NO.:Previous Titles Is this invention related to a previous invention? Yes No If YES, Project ID: Inventors + Inventors should include only those persons that are believed to have contributed to the concepts included in the invention. Should the IPC proceed with patent filing, patent counsel will separately investigate and make a final legal determination of inventorship of patent applications in accordance with applicable patent laws. + The Contribution % should reflect each inventors contribution to the concepts of the invention and be agreed upon by all inventors. If the inventors cannot agree to contribution percentages, the IPC will assume an equal distribution.Full Name:Citizenship:Employer at time of invention:Title:Department:Home Address: Phone: Fax: Email:Contribution %:Execution by Inventor(s): I/We inventor(s) hereby solemnly swear and affirm under oath that I/we am/are the only inventor(s) of this invention and that I/we have not knowingly omitted the inclusion of any other inventor(s) besides me/us, and that the information provided in this disclosure is, to the best of my/our knowledge, true and accurate.Signature: Date:Full Name:Citizenship:Employer at time of invention:Title:Department:Home Address: Phone: Fax: Email:Contribution %:Execution by Inventor(s): I/We inventor(s) hereby solemnly swear and affirm under oath that I/we am/are the only inventor(s) of this invention and that I/we have not knowingly omitted the inclusion of any other inventor(s) besides me/us, and that the information provided in this disclosure is, to the best of my/our knowledge, true and accurate.Signature: Date: Full Name:Citizenship:Employer at time of invention:Title:Department:Home Address: Phone: Fax: Email:Contribution %:Execution by Inventor(s): I/We inventor(s) hereby solemnly swear and affirm under oath that I/we am/are the only inventor(s) of this invention and that I/we have not knowingly omitted the inclusion of any other inventor(s) besides me/us, and that the information provided in this disclosure is, to the best of my/our knowledge, true and accurate.Signature: Date:Full Name:Citizenship:Employer at time of invention:Title:Department:Home Address: Phone: Fax: Email:Contribution %:Execution by Inventor(s): I/We inventor(s) hereby solemnly swear and affirm under oath that I/we am/are the only inventor(s) of this invention and that I/we have not knowingly omitted the inclusion of any other inventor(s) besides me/us, and that the information provided in this disclosure is, to the best of my/our knowledge, true and accurate.Signature: Date:Invention DescriptionBrief Description: Why is the research/current invention more advantageous than present technology? What are the novel and unusual features of the present invention? What problems does it solve? PLEASE ATTACH MORE DETAILED DESCRIPTIONS, ANY SUPPORT MATERIALS, REPORTS AND PROPOSED PUBLICATION. Source of SupportDid this invention result from sponsored research? Yes No If NO, how was this work funded, including salaries, charges of materials, supplies, and equipment? If YES, please provide information on all sponsors: Sponsor: Project Number:: Sponsor: Project Number : Did you use any material obtained from another party in developing this technology? Yes No If YES, please provide all information regarding agreementsEstablishment of Invention History + Please provide your best estimate for the date when the following occurred (will occur):Date:(mm/dd/yyyy)Conception of invention by whom: ______________________First written description (please attach a copy if available) Who observed progress of experimental work? ______________First public disclosure giving an enabling description of your invention (e.g. abstract, proposal, paper submission, talk, or meeting with industry please attach a copy if available) to whom: ________________________________Completion of model or prototypeFirst successful operational testIs a publication, paper or other disclosure planned within the next 6 months? Yes NoPrior Art List any patents, publications, or other references relevant to current invention.Commercialization PotentialWhat are the commercial applications for the invention? What are the limitations that must be overcome prior to practical application? What are the advantages of the invention versus present technologies? Please provide any available data or information on market potential/size. Is work on the invention continuing? Yes No If Yes, please provide source of on-going funding: Do you know of any appropriate industrial organizations that may be interested in licensing this technology? (Please attach additional sheet if more space is required.)Company NameContact PersonContact InformationExecution by Witnesses + This disclosure should be witnessed by two individuals who are not co-inventors and who are technically qualified to understand the subject matter.Print NameSignatureDateI have read this invention disclosure (including attached pages, if any) and understand its subject matterI have read this invention disclosure (including attached pages, if any) and understand its subject matter Part B Copyright Disclosure Form Please complete all fields and return to the above address. If you have any questions, please call (270)809-3744. TitleTitle of the Copyrightable Work: MSU FOAPAL OR OSP NO.:Previous Titles Is this work related to a previous copyrightable work? Yes No If YES, Project ID: Authors + Authors should include only those persons that are believed to have contributed to the concepts included in the copyrightable work. Should the IPC proceed with copyright protection, counsel will separately investigate and make a final legal determination of authorship in accordance with applicable laws. + The Contribution % should reflect each authors contribution to the copyrightable work and be agreed upon by all authors. If the authors cannot agree to contribution percentages, the IPC will assume an equal distribution. Full Name:Employer at time of work:Title:Department:Home Address: Phone: Fax: Email:Contribution %:Execution by Author(s): I/We author(s) hereby solemnly swear and affirm under oath that I/we am/are the only author(s) of this copyrightable work and that I/we have not knowingly omitted the inclusion of any other author(s) besides me/us, and that the information provided in this disclosure is, to the best of my/our knowledge, true and accurate.Signature: Date: Full Name:Employer at time of work:Title:Department:Home Address: Phone: Fax: Email:Contribution %:Execution by Author(s): I/We author(s) hereby solemnly swear and affirm under oath that I/we am/are the only author(s) of this copyrightable work and that I/we have not knowingly omitted the inclusion of any other author(s) besides me/us, and that the information provided in this disclosure is, to the best of my/our knowledge, true and accurate.Signature: Date: Full Name:Employer at time of work:Title:Department:Home Address: Phone: Fax: Email:Contribution %:Execution by Author(s): I/We author(s) hereby solemnly swear and affirm under oath that I/we am/are the only author(s) of this copyrightable work and that I/we have not knowingly omitted the inclusion of any other author(s) besides me/us, and that the information provided in this disclosure is, to the best of my/our knowledge, true and accurate.Signature: Date: Full Name:Employer at time of work:Title:Department:Home Address: Phone: Fax: Email:Contribution %:Execution by Author(s): I/We author(s) hereby solemnly swear and affirm under oath that I/we am/are the only author(s) of this copyrightable work and that I/we have not knowingly omitted the inclusion of any other author(s) besides me/us, and that the information provided in this disclosure is, to the best of my/our knowledge, true and accurate.Signature: Date:Copyright Description Title of the Copyrighted Work:  Type of Copyrighted Work: Software; _____Book;_____Article; _____Video; _____Film; _____Other __________________________________________________  Please Describe: PLEASE ATTACH MORE DETAILED DESCRIPTIONS. Source of SupportDid this copyrightable work result from sponsored research? Yes No If NO, how was this work funded, including salaries, charges of materials, supplies, and equipment? If YES, please provide information on all sponsors: Sponsor: Project Number:: Sponsor: Project Number : Was work developed in connection with a separate agreement with the University? Yes No If YES, please attach a copy of the executed agreement Did you use any material obtained from another party in developing this work? Yes No If YES, please provide all information regarding agreements Is the work considered to be a Traditional Academic Work as defined in the Faculty Handbook, Section 2.13.2.4 (A)? Yes No If YES, please provide basis for this determination Commercialization PotentialIs work on the copyrightable work continuing? Yes No If Yes, please provide source of on-going funding: Please provide any available data or information on market potential/size. Do you know of any organizations/entities that may be interested in this copyrightable work? If Yes, please provide information as noted below and attach additional sheet if more space is required. 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