Office of IP Commercialization & Economic Development

INTELLECTUAL PROPERTY DISCLOSURE FORM

INSTRUCTIONS:

  1. COMPLETE ALL SECTIONS, ELECTRONICALLYSUBMIT the completed form (pages 1-2 and any additional attachments), to .
  2. ALL INVENTORS LISTED NEED TO SUBMIT A SIGNED ORIGINAL HARD COPY OF APPENDIX Ato IP Commercialization & Economic Development, Stop 7095.
  3. ALL Inventors should retain a copy of Intellectual Property Disclosure and Appendices for their records.

Title of Intellectual Property (descriptive-process / method or composition):

Detailed Description of the Intellectual Property:(limit to form and add figure drawings, if necessary)

What isapplication or objective of your intellectual property? Please develop commentary to address the following questions.

1.Describe the key features of your Intellectual Property:

2.What are the applications of this Intellectual Property?

3.How is this Intellectual Property different from existing technology?

4.Why is this Intellectual Property better than existing technology?

5.Please list key words to use in patent and literature searches:

6.Is your Intellectual Property presently being used by anyone at UND and, if so, by what department(s) or person(s)? How could UND use you Intellectual Property in the future?

Dates and Places of Inventions:

1.Conception by inventor:

2.First sketch, drawing, or lab notebook entry:

3.First written description:

4.Completion of model or full sized device:

5.First time successfully tested:

6.First commercial use:

Sponsorship: Attach additional pages, if necessary.

Funding Source: Federal State Corporate UND Other
Name of Sponsor / Grant/Contract Number / UND Project Number

Collaborating Institution/Company or Other Research Support: Attach additional pages, if necessary.

Collaborating Institution/Company Name / Collaborating Investigator’s Name
Did you use materials, equipment, or software from another institution/company? Yes No
Describe your use of collaborating materials, equipment, or software:

Public Disclosure Events: Accurate information is essential because prior disclosures may affect the chances of securing patent rights. Public Disclosures include any published abstracts, publications, meetings and/or presentations concerning the Invention. Carefully consider all events relating to your Invention that fall into the below categories and attach copies of published or submitted versions.

Poster Presentation: / Yes No / Date: / Published Abstract: Yes No
Submitted to a Journal: / Yes No / Date: / Journal Name:
Published: / Yes No / Date: / Journal Name:
Oral Disclosure: / Yes No / Date: / Published Abstract/Handouts: Yes No
Poster Presentation: / Yes No / Date: / Published Abstract: Yes No
Thesis: / Yes No / Date:
Website: / Yes No / Date:
Other Disclosure: / Yes No / Date: / Describe:
Public/or commercial use/sale: / Yes No / Date: / Describe:
Any Future Disclosures planned: / Yes No / Estimated Date: / Describe:

Commercial Interest: Attach additional pages, if necessary.

Company Name / Contact Person / Phone Number/E-mail
Is an agreement in place? Yes No
What kind? MTA Confidentiality Research Agreement
If yes, please attach a copy of the fully executed agreement.

Inventor Data / Primary Contact Person: Attach additional pages, if necessary. Fields marked with an * are fields required by the USPTO to file a patent application.

Name*: / Campus Address/Dept.:
Home Address*: / Title:
City/State/Zip*: / Citizenship*:
E-mail:
Home Phone: / Office Phone: / Fax:

Inventor Data:

Name*: / Campus Address/Dept.:
Home Address*: / Title:
City/State/Zip*: / Citizenship*:
E-mail:
Home Phone: / Office Phone: / Fax:

Inventor Data:

Name*: / Campus Address/Dept.:
Home Address*: / Title:
City/State/Zip*: / Citizenship*:
E-mail:
Home Phone: / Office Phone: / Fax:

Inventor Data:

Name*: / Campus Address/Dept.:
Home Address*: / Title:
City/State/Zip*: / Citizenship*:
E-mail:
Home Phone: / Office Phone: / Fax:

Appendix A:ALL INVENTORS LISTED MUST SUBMIT A SIGNED ORIGINAL HARDCOPY OF APPENDIX A TO IP COMMERCIALIZATION & ECONOMIC DEVELOPMENT, BOX 7095.

Page 1 of 3

APPENDIX A:

ASSIGNMENT OF INVENTION RIGHTS

Name:
University of North Dakota Identification Number (EMPLID):

In consideration of:

my continued, present and/or future employment at the University of North Dakota (hereinafter “Institution”); and/or

my status as a graduate student at the Institution; and/or

my participation as faculty, student, volunteer, trainee or staff in research or in an investigation performed at the Institution; and/or

opportunities made or to be made available to me to make significant use of the Institution funds or facilities; and/or

opportunities made or to be made available to me to share in royalties and other inventor/author rights outlined in the Institution’s Intellectual Property Policy

I hereby agree to abide by all provisions of the University of North Dakota’s Intellectual Property Policy and Procedures which are hereby incorporated by reference and I hereby:

A. Agree to comply with the Institution’s Intellectual Property Policy and Procedures which applies to all Inventions made by the Institution’s faculty, staff, students, trainees, volunteers or others if such Inventions are:

i)the result of research performed by or under the direction of any faculty member, staff or student, the cost of which was partially or wholly paid for with funds under the control of or administered by the Institution and/or

ii)the result of an investigation by the faculty, staff, students, trainees, volunteers or others utilizing the Institution’s facilities, laboratories or other resources available to such faculty, staff, students, trainees, volunteers or others because of their status within the Institution.

B.Agree to disclose promptly to the Office of Intellectual Property Commercialization and Economic Development, full information concerning intellectual property, inventions, discoveries or know-how (hereinafter “Invention”) that may be made in the course of any such research, investigation or training program;

C.Assign to the Institution or its designee all of my rights, title, or interest in and to such Inventions, patent applications, patents, certificates of Plant Variety Protection, or the like, including copyright in original works related to, incidental to, or necessary for the practice of, such Inventions;

D.Agree to execute all necessary papers and otherwise provide proper assistance at the Institution’s expense, during and subsequent to the period of my Institution affiliation, to enable the Institution to obtain, maintain, or enforce for itself or its nominees, patents, or other legal protection for such Invention;

E.Agree to prepare and maintain for the Institution adequate and current written records of all such Inventions; and

F.Agree, upon request, to deliver promptly to the Institution copies of all written records referred to in Paragraph E above as well as all related memoranda, notes, records, plans, or other documents.

This agreement may not be modified or terminated, in whole or in part, except in writing, in which case it will be signed by an authorized representative of the Institution. Rights and obligations under this agreement shall survive any termination of enrollment or employment at the Institution.

Signature: / Date:
SIGN IN BLUE INK