Technology Application Form

Name of Innovation/Enterprise: ______

Date: ______

Contact Information

  1. Name of research facility or enterprise: ______

Website home page:

  1. Inventor Contact:

First Name: ______Last Name: ______

Title:

Telephone:

Mobile Phone:

Email:

Mailing Address:

  1. Administrative Contact (Secretary):

First Name: ______Last Name: ______

Telephone:

Mobile Phone:

Email:

Part 1. Technology Description

  1. Brief description: What is it? (a new composition of matter? a device? an algorithm? a new process? other?)
  1. Keywords: Provide a list of words, common industry phrases, and/or categories.
  1. Provide a technical description or abstract of the innovation. (100 words maximum)
  1. Explain the problem(s) that this innovation was created to solve or address. (70 words maximum)
  1. Explain how this innovation addresses or solves the problem(s) described in Question 4 above. (Please do not divulge any sensitive or proprietary information that might compromise intellectual property, 70 words maximum)
  1. Suggest several possible alternate uses for this innovation.

Part 2. Development Status

  1. What is the current status of this innovation? (Choose the single best answer)

Concept only

Successful laboratory model

Full-scale prototype

In-field testing or trials

Fully implemented / in use

  1. How many calendar months will be required before this innovation is fully implemented? (Choose the single best answer)

None – in active use now

1-3 months

4-6 months

7-12 months

13-18 months

More than 18 months

  1. What is the total investment (including manpower, equipment and other resources) required to complete development of this innovation? (Choose the single best answer)

None-in active use now

Less than US$100,000.00

Less than US$250,000.00

Less than US$500,000.00

More than US$500,000.00

  1. What is the role that the inventor desires to play in the commercialization of this innovation? (Choose the single best answer)

Management

Consultant / Advisor

No role in process

Other (define) ______

Part 3. Intellectual Property Status

  1. What is new and novel about this innovation? Is there value that may not be seen upon the first review? Be specific about benefits of the technology.
  1. Has this innovation been granted any Spanish patents?

Patent request has not been filed.

Patent request has been filed.

Patent is pending.

Patent has been granted.

Patent filing has been turned down.

  1. List the Spanish patents that have been granted to this innovation:

Patent Name / Patent Number / Patent Grant Date / Patent Owner
  1. Has this innovation been granted any patents by other nations or patent granting agencies?

No patents have been granted.

A patent is pending in (insert name of countries)

A patent has been granted

Patent request has not been filed

  1. List the patents that have been granted by other nations or patent granting agencies (PCT, etc.):

Patent Name / Patent Number / Granting Nation/Agency / Patent Grant Date / Patent Owner

Provide copy of abstracts of patents mentioned above with documents in Section 8.

Part 4.Markets and Market Interest

  1. Which industry sectors might be interested in this technology?
  1. Have you spoken with any companies/investors who have expressed interest in this technology for possible usage, partnership or investment? (Provide contact names and data)
  1. What is your ideal business model?

I prefer to license my technology to another company

I prefer to create a company and sell my technology

Other ______

Part 5. Competition

  1. Describe competing technologies, including:

current solutions for the same problem(s)

related patents or published technical papers

degree of research vs. commercial interest in solving this problem

current market leaders in the field

  1. How much better is your innovation (for example, X times faster, more efficient, cheaper) than solutions already being used in the market today?

Part 6. Risks and Barriers

What risks and obstacles do you expect to encounter while commercializing your technology? State how you plan to reduce the risks and address the obstacles.

Part 7. Team Status

List the people involved with developing and/or commercializing your innovation. Include a brief explanation of their background and experience as it relates to your technology, and how they are helping. Also list any positions currently not staffed that you expect to need in the future, with justification for their addition to the team.

Part 8. SupplementalDocumentation

Provide documents, diagramsand additional information that will aid in describing this innovation. Do not provide any confidential information. Please provideany patent abstract information here.