Please complete, sign, and return this form (with attachments) to TCO:
New Technology Disclosure
Technology Commercialization Office
The City University of New York
555 West 57th Street, Suite 1407
New York, NY 10019
Please ALSO send the completed NTD form electronically (if available) to TCO:
E-mail:
1. Title of Invention: (Give your invention, discovery or new technology a short descriptive title)
[Key Words: ]
2. Inventors
List the names of all CUNY or non CUNY individuals who have contributed to this invention.
Nature and percentage of contribution to be discussed with TCO after submission.
Name & Title / AffiliationCollege/ Department / - Telephone
- Email / Office Use Only
(per discussion)
3. Primary Contact (The person whom CUNY Technology Commercialization Office may contact with all questions and correspondence)
4. Invention Description
A. Type of your invention, discovery or new technology (Please check all that may apply)
Compound Diagnostic Tool
Organism/Material Therapeutic/Prevention
Device Software/Algorithm
Method/Process Video
A new use for or an improvement to an existing product or process
Other (specify):
B. Stage of Development (Please check all that may apply)
Concept
Model in Process
Working Model Made
Proof-of-concept Data Obtained
Tested in in vitro models (including cell culture):
Tested in animal modes:
Tested in human subjects:
Other (specify):
C. What is the purpose and utility of the invention in general terms?
Use as much space as necessary.
D. What un-met needs does this invention fulfill in the relevant field?
Use as much space as necessary.
E. Describe the invention in detail, including its physical characteristics and operation and the process of making it. Please include test data (if available) proving its utility.
Use as much space as necessary. Attach any papers, drawings etc. to the Form.
F. List any Existing Technology and/or Prior Art (journal citations, patents, general knowledge or other public information) which describes a similar invention, materials, methods, processes or devices performing a similar function. What are the significant technical differences? What are the advantages of your invention?
Use as much space as necessary.
G. In addition to immediate applications you provided in 4C, please suggest other possible uses that might be realized in the future even if outside your area of expertise.
Use as much space as necessary. List and describe in order of importance.
5. Research Support information:
A. Please provide the following relevant information for each funding source under which the invention was developed.
Title of Grant / Granting Agency / Grant Number (Award/contract or RF/Campus Account #)U.S. Government [ ]
Industry Sponsor [ ]
CUNY [ ] Personal [ ]
U.S. Government [ ]
Industry Sponsor [ ]
CUNY [ ] Personal [ ]
U.S. Government [ ]
Industry Sponsor [ ]
CUNY [ ] Personal [ ]
B. Please list the names of institutions or companies which have provided material (i.e. vector, antibody, compound, etc.), software, or equipment that has had impact upon development of the invention and whether such is subject to a Material Transfer Agreement or other agreement. Please describe the material and provide a copy of the relevant Agreement.
C. Please list the names of institutions or companies which have received or want to receive any materials (i.e. vector, antibody, compound etc.) related to this invention/technology from your laboratory. Please describe the material and provide a copy of any relevant Agreement.
6. Public Disclosure (“Public Disclosure” for this purpose means non-confidential communications to members of the public, including oral presentations at a public meeting by you or others, invited talks to a company, published scientific papers, and published abstracts of talks or posters, etc.) Please contact Technology Commercialization Office if you have any questions.
A. Please list any previous Public Disclosure(s) describing the invention; please provide exact details such as dates, title of conference and/or copies of any publications.
B. If there is no previous disclosure, will Public Disclosure happen in the immediate future? For example, have you submitted a manuscript that is being peer-reviewed, or an abstract to an upcoming conference? Please provide date (estimate if unknown), title of conference or journal, and attach copies of manuscripts, preprints or abstracts, etc.
C. If the answer to both of the above questions is no, do you plan to publish the invention or give oral presentation about the invention?
If yes, please provide an estimated timeframe.
7. Commercialization:
A. Has the invention been disclosed to industry representatives? Has any industry entity contacted you with commercial interest? Please provide contact information.
B. If the invention was discussed with a company, was the discussion covered by a Non-Disclosure or Confidentiality Agreement?
Please provide the company’s name and a copy of the Agreement.
C. List companies that you believe would be interested in commercializing the technology or which may be doing similar research.
Please provide contact information if available.
The following section must be completed in order for an invention to be evaluated
8. Declaration and Signature of Inventors. Attach additional sheets if there are more inventors. It is the inventor’s responsibility to notify TCO of any address changes.
I hereby declare that all statements made herein of my own knowledge are true and that all statements made on information and belief are believed to be true.Declaration of CUNY inventors: In view of my (our) obligations under the CUNY IP Policy (copy available upon request), I (we) hereby assign all rights, title and interest to this invention to the Research Foundation of CUNY (RFCUNY), and agree to execute all documents as requested for assigning to RFCUNY my (our) rights in any patent application(s) filed on this invention, and to cooperate with the Technology Commercialization Office (TCO) in the protection and commercialization of this invention.
Declaration of Non-CUNY inventors: I have disclosed (or will disclose) this invention to my home institution.
Inventor Signature: Signature:
Date: Date:
Name: (Dr.,Ms.,Mr.) Name: (Dr.,Ms.,Mr.)
Affiliation (if not CUNY): Affiliation (if not CUNY):
Country of Citizenship: Country of Citizenship:
Social Security No: Social Security No:
Home address: Home address:
Inventor Signature: Signature:
Date: Date:
Name: (Dr.,Ms.,Mr.) Name: (Dr.,Ms.,Mr.)
Affiliation (if not CUNY): Affiliation (if not CUNY):
Country of Citizenship: Country of Citizenship:
Social Security No: Social Security No:
Home address: Home address:
CUNY New Technology Disclosure Form 5
Technology Commercialization Office, The City University of New York
555 West 57th Street, Suite 1407, New York, NY 10019
Tel: 646-758-7910; Fax: 646-758-7907; Email:
CUNY will share any royalty income derived from the invention with the inventor(s) according to CUNY IP Policy.
CUNY New Technology Disclosure Form 5
Technology Commercialization Office, The City University of New York
555 West 57th Street, Suite 1407, New York, NY 10019
Tel: 646-758-7910; Fax: 646-758-7907; Email: