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INVENTION DISCLOSURE FORM (USE CONTINUATION SHEETS AS NECESSARY)
1. Inventor(s) - Full name (including middle initial), address and phone number and Nationality (i.e., U.S.A.): __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
2. Will this Invention be assigned to a company or another entity? ( )Yes ( )No If yes, Name of entity:___________________________________________ Type of entity (corp., partnership, etc.):_______________________ State of incorporation, partnership, etc.: ______________________ Address for entity: ______________________________________ ____________________________________ 3. Title of Invention: ________________________________________________________ ________________________________________________________ 4. Date when invention first thought of: __________________________________________ Is this date documented in writing? ( )Yes ( )No.
5. Has a working model been made? ( )Yes ( )No. If so, when? _____________________________________________________ 6. Has the invention been: a. Offered for sale or sold? ( )Yes ( )No When? _________________________________ b. Described in a Publication? ( )Yes ( )No When? _______________________________ c. Publicly used/demonstrated? ( )Yes ( )No When? ______________________________
7. Background of the invention: a. What is the problem solved by the invention? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ b. How was problem solved before the invention? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
c. Why does the invention solve the problem better? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
d. List or describe the closest related patents, publications or products known. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
8. Describe the invention in detail: a. What are its basic components? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
b. Which components are essential and why? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
c. How are the components connected or organized? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
d. How does it operate (function or steps)? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
e. How does someone use the invention? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
f. How does the invention accomplish its objectives? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ g. What limitations exist (i.e., temperature, quantities, sizes or materials)? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
9. What variations (i.e., materials, components or functions) to your invention are currently known? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
10. Additional pages attached: a. ____ pages of continuation sheets for items above. b. ____ pages of drawings, sketches, photographs and/or documentary evidence of date of invention.
INVENTION DISCLOSURE FORM CONTINUATION SHEET
Continuation of Paragraph number: _____ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
Continuation of Paragraph number: _____ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
Continuation of Paragraph number: _____ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
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