Application for Licensing

APPLICATION FOR LICENSING

US ENVIRONMENTAL PROTECTION AGENCY INTELLECTUAL PROPERTY

SECTION 1: IDENTIFICATION OF INVENTION(S) FOR WHICH LICENSE IS SOUGHT

Title of Patent Application(s):

Inventor(s):

Source from which you learned of availability of a license to the present invention(s):

SECTION 2: INFORMATION ABOUT APPLICANT

Name of Applicant's Primary Contact Person:

Title:

Address:

Phone: ( )

Fax: ( )

E-Mail:

Name of Applicant’s Licensing Representative:

Title:

Address:

Phone: ( )

Fax: ( )

E-Mail:

Is Applicant a U.S. Corporation? ____ Yes ____ No

If no, state country of origin:

State of incorporation or citizenship (if an individual):

Is Applicant a Small Business Firm (<500 employees)? __ Yes ____ No

Number of employees:

Type of License sought (please circle one):

____ Exclusive Commercialization License ____ Nonexclusive Commercialization License

Location of manufacturing facilities:

Where would this technology be manufactured?

Do you have any of the following arrangement(s) with the EPA:

____ Contracts ____ Grants/cooperative agreements ____ CRADAs ____ Other

____ MTAs ____ Voluntary partnerships ____ Licenses ____ None

If yes to any of the above, please specify:

Are any of those checked above related to this license application? ____ Yes ____ No

If yes, please explain:

SECTION 3: BUSINESS PLAN

On a separate attachment to this application, please provide the following information:

Description of Applicant: Include nature and type of applicant’s business; corporate/divisional commitment to R&D, production, sales & marketing; financial resources; products or services successfully commercialized; and any unique capabilities of your company relative to the licensed technology.

Other Licenses and Use of the Invention: Identify licenses previously granted to the Applicant for federally-owned inventions. Also, identify, to the best of Applicant’s knowledge, the extent to which the invention for which a license is sought is being practiced by private industry or Government, or is otherwise available commercially.

Proposed License Terms: Include definitions of licensed products, processes or methods; geographic territories; duration of license; field(s) of use desired; and other terms for which you wish to make a proposal at this time.

Research & Development, and Marketing Plan: Include description of product(s) or method(s) to be developed with the licensed technology and, for each product or method to be developed, a description of expected product research and development programs, including major manufacturing and marketing stages; monetary and personnel commitments for each development stage; and the projected time to accomplish each stage of commercial development.

Market Analysis: Include relevant market segment(s) the licensed technology will serve when commercialized; market size and projected growth of relevant markets during the duration of the license; estimated market share once product is introduced; and specific sales projections for the first five (5) years based on market share analysis. Estimates should include gross sales and net margin information.

Include a statement containing applicant=s best knowledge of the extent to which the invention is being practiced by private industry or Government, or both, or is otherwise available commercially. Also include your proposed marketing and deployment strategy.

Please provide any other information which will support a determination to grant the requested license.

For Applicants for Exclusive or Partially Exclusive Licenses ONLY: Include a detailed statement as to a) why federal and public interests will be best served by exclusive licensing of this invention; b) why expeditious practical application of the invention is unlikely to occur under a nonexclusive license; c) why the exclusive licensing of this invention is a reasonable and necessary incentive to attract investments of risk capital; d) why the exclusive licensing of this invention will not tend substantially to lessen competition or result in undue market concentration; and e) why the proposed license terms and scope of exclusivity are not greater than reasonably necessary.

I certify, to the best of my knowledge, that all of the information provided on this application and on attachments to this application is true and accurate.

Signature of Applicant or Authorized Representative Date

Please Print Name and Title: