Date of 1St Use Anywhere (Trademarks)

Title:
Description of copyrighted material(Please also attach manuscripts, PowerPoint or other presentations, posters or abstracts):

Year created:
Contributors (Provide a list of all WSU-affiliated and non-WSU contributors and a brief description of the contributions made by each. Contact information of each contributor must be completed on page 3):

Name / Contributions

Year first published:
Date of 1st use anywhere (Trademarks):
Date of 1st use in commerce (Trademarks):
Class(es) and Goods/services (Trademarks):
Incorporated Elements: identify any program codes (open source, free executable, public domain, etc), data files or other incorporated elements (including text, voices or other sounds, graphics or other images that are not original). Also include the URL or copyright statement for each incorporated element.

Sponsorship:Was this material developed with the use of any WSU administered research grant/contract funds?

No Yes – please provide details:

Grant/Contract No(s):Sponsor(s):

Is there any third party involvement, such as collaboration with another university, sponsored research agreement, consulting etc?

No Yes – please provide details:

Please list commercial entities that may be interested in the material.What do you see as the best commercialization venue for this creation?

13.CONTRIBUTOR DATA SHEET: By signing below, each contributor certifies that he or she is a contributor, that the others named hereinare contributors, and that there are no other contributors, to the best of his or her knowledge. If your contact information changes, it is your responsibility to notify WSU Ventures of your new address. If you cannot be contacted, any applications may be abandoned and/or you will not receive any royalties.

WSU-AFFILIATED CONTRIBUTORS:

NON-WSU-AFFILIATED CONTRIBUTORS:

FACULTY AND/OR EMPLOYEE CERTIFICATION (for non-WSU and Student contributors, leave blank): Pursuant to WSU policy, I hereby acknowledge WSU’s ownership in the intellectual property described and disclosed in this form and hereby assign all of my right, title and interest to this intellectual property to WSU. This assignment includes both the right to claim priority and all rights in the invention. Wichita State University will share any net royalty income derived from the intellectual property with the inventor(s) according to the published policies.

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