Technology Transfer Office of Research Florida State University

Materials Disclosure and Assignment Form

Office of Commercialization § Florida State University

Materials Disclosure and Assignment Form

This Confidential form is used to disclose a physical or biological entity that is useful in research. as required under Florida State University (FSU) Policies (Explained in Policy on Patents and University-Sponsored Educational Materials. please respond to each Question even if the answer is "none" or "not applicable". For questions regarding this form, please call the office at (850) 644-3328.

I. Description

Use additional sheets and attach descriptive materials to expand answers to questions. (Sketches, drawings, photos, reports and manuscripts are helpful.)

A. Title. Be sure to be broad, non-confidential and communicate utility.
B. Abstract/Description.
C. Select Materials Type (check the most appropriate one). Also, please indicate the species of origin.
☐ Plasmid
☐ expression
☐ shuttle
☐ cloning
☐ Antibody
☐ polyclonal
☐ monoclonal (classical)
☐ monoclonal (genetically modified – humanized, chimeric, etc)
☐ Transgenic animals
☐ rodents
☐ livestock
☐ dogs/cats
☐ other ______
☐ Transgenic plants
☐ Transgenic microorganisms
☐ Cell lines
☐ mammalian
☐ yeast
☐ bacterial
☐ plant / ☐ Assay/Kit
☐ enzymatic activity
☐ quantitation of molecule in biological medium
☐ high throughput screening
☒ other ______
☐ Genetic Library
☐ phage library
☐ cDNA library
☐ induced expression library
☐ Chemical/Biochemical Entity
☐ small molecule
☐ encoded or expressed chimeric protein
☐ peptide with synthetic amino acids
☐ naturally occurring peptide
☐ Other (please describe) ______
D. Has information describing your material been disclosed in an abstract, paper, news article, thesis, etc
Yes Title ______
No - please skip to F
E. Has the material been presented orally in a public or private forum?
Yes To Whom? ______When? ______Where? ______
No
F. Have you sold or offered for sale any products that utilize your material?
Yes To Whom? ______When? ______Where? ______
No
G. Have you allowed others outside of the University to use your biological materials?
Yes To Whom? ______When? ______Where? ______
No
H. Please list all government funding or third party sponsorship that supported the development of materials.
Name: ______Grant Number: ______
I. What present technology exists that solves the same or similar problems? Why is the disclosed material better, more advantageous than present technology? What problems does it solve? What are its novel and unusual features?
J. Are you the sole Investigator?
Yes
No - Please list the names , departments/institutions of the other co-PIs
______
______
______
______
K. For any of the people listed in J listed during the last five years has anyone signed any documentation or agreements of any type during a visit to an outside entity such as a commercial or government research lab, or been employed by another entity claiming ownership of intellectual property of its employees? Use more paper if needed.
Yes To Whom? ______
When? ______
Where? ______
No
L. I (we) declare that all statements made herein of my own knowledge are true and accurate and that all statements made on information and belief are believed to be true.
II. Assignment

I (WE) hereby assign all rights, title and interest to this material to the FSU Research Foundation (FSURF) and agree to execute all documents as requested, assigning to FSURF any rights in the Material, and to cooperate with the FSU Office of Commercialization (“OoC”) in the transfer of the material. FSURF will share any royalty income derived from the license of the material with the persons listed below according to its standard policies (http://facultyhandbook.fsu.edu/Section-6-Policies-and-Procedures#Patents) as may be updated from time to time.

Signature: / Date / Signature: / Date
Full Name: / Full Name:
Department: / College: / Department: / College:
Phone: / Fax: / e-mail: / Phone / Fax / e-mail:
Permanent Address: / Permanent Address:
City: / State: / Zip: / City: / State: / Zip:
FSU ID (required)*: / Birth Month/Day*: / FSU ID (required)*: / Birth Month/Day*:
Country of Citizenship: / Country of Citizenship:
Percent Share of Royalties ______/ Percent Share of Royalties ______
Signature / Date / Signature / Date
Full Name: / Full Name:
Department: / College: / Department: / College:
Phone / Fax: / e-mail: / Phone / Fax / e-mail:
Permanent Address / Permanent Address:
City: / State: / Zip: / City: / State: / Zip:
FSU ID (required)*: / Birth Month/Day*: / FSU ID (required)*: / Birth Month/Day*:
Country of Citizenship: / Country of Citizenship:
Percent Share of Royalties ______/ Percent Share of Royalties ______
Signature: / Date / Signature: / Date
Full Name: / Full Name:
Department: / College: / Department: / College:
Phone: / Fax: / e-mail: / Phone / Fax / e-mail:
Permanent Address: / Permanent Address:
City: / State: / Zip: / City: / State: / Zip:
FSU ID (required)*: / Birth Month/Day*: / FSU ID (required)*: / Birth Month/Day*:
Country of Citizenship: / Country of Citizenship:
Percent Share of Royalties ______/ Percent Share of Royalties ______
*Please note that FSU is now collecting FSU ID numbers and month and day of birth rather than social security numbers for security and privacy reasons. This information as well as country of citizenship is required. Absence of this information may hinder the distribution of the any royalties that may result from this technology.
III. Department Chair and Dean Information
The department chairperson and Dean (or their equivalents) of each Person listed in Section II should sign below to confirm the University contribution, and Contract and Grant support, to the Material. Copy this page if additional Chair/Dean signatures are needed.
A. Signature of Department Chairperson(s)
Chair 1 / Chair 2
Department
Name
Signature
Date
B. Signature of Dean(s)
Dean 1 / Dean 2
Department:
Name:
Signed:
Date:

Mail or Hand-deliver this form to:

The Florida State University

Office of Commercialization

95 Chieftan Way, 312 Dittmer Building

(Across from the Dirac Science Library)

Tallahassee, FL 32306-4391

Phone: 850/644-9318

Last revised 8/29/2014

CONFIDENTIAL