MATERIALDISCLOSURE FORM

  1. Material name:
  1. Material type:

AnimalAntibody CellTissue

Plasmid (DNA)Software Small Molecule Peptide Video Clip

  1. Developer* :
  1. Have there been public disclosures (e.g., a presentation, publication, abstract, etc.) or was it included (described or claimed) in any patent application? Please provide details:

5.Was the research project that led to the development of the Material sponsored by any source of public or private funding (for example commercial entities, foundations, public or private organizations, EU projects, Yeda CEO Fund, Hurwitz fund, Levine fund, ISF, GIF, NIH, DIP, BSF, US Army, ICRF, Ministry of Science, Ministry of Health, Israeli Ministry of Defense work order, Nofar, Magneton, Magnet, etc.)?

Yes

No

If yes, please provide details:

A marked “No” in the above check box constitutes a declaration and a warranty by the undersigned that the developers have not and will not include a description of the Material disclosed in this document in any report under a grant.

6.During the course of your work on developing this Material, were you or any of the Developers salaried with or employed by any organization other than WIS?

Yes

No

If yes, please provide details. The relative ownership (%) between WIS and the other organization should be indicated.

  1. Has the material already been shared with/transferred to any other researchers (from academia or commercial entity) prior to the report to Yeda?

Yes If yes: Academic Commercial

No

If yes, please provide details of these researchers (name, affiliation, etc):

Also, If yes, was a Material Transfer Agreement used to cover this transaction?

Yes

No

If yes, please enclosed a copy of the MTA.

  1. Is the new Material related to (progeny, derivative) or produced by the use of, a material which was received from a third party (from or outside WIS)?

Yes

No

  1. If yes, was the material received under a Material Transfer Agreement?

Yes

No

If yes, please enclosed a copy of the MTA.

  1. Has the new Material been developed, in whole or in part, as a direct result of using the Celera database?

Yes

No

Submitted to Yeda by:

Date:

Signature:

DEVELOPER INFORMATION

To ensure the accuracy of legal documents, please supply the following information.

  1. Name of Developer:

I.D.#:

Citizenship :

Title:

Degree:

Department:

Phone :

Fax :

Home Address:

Phone: Fax:

  1. Name of Developer:

I.D.#:

Citizenship :

Title:

Degree:

Department:

Phone :

Fax :

Home Address :

Phone:Fax:

  1. Name of Developer:

I.D.#:

Citizenship :

Title:

Degree:

Department:

Phone :

Fax :

Home Address :

Phone:Fax:

  1. Name of Developer:

I.D.#:

Citizenship :

Title:

Degree:

Department:

Phone :

Fax :

Home Address:

Phone:Fax:

  1. Name of Developer:

I.D.#:

Citizenship :

Title:

Degree:

Department:

Phone :

Fax :

Home Address:

Phone:Fax:

  1. Name of Developer:

I.D.#:

Citizenship :

Title:

Degree:

Department:

Phone :

Fax :

Home Address:

Phone:Fax:

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No. : 56506