When Completed, Submit to the

PurdueUniversity

Request for Open Source Distribution of Software

This Request for Open Source Distribution must be reviewed and approved by Submitters’ Department Head and Dean and the Center Director if any funding for the work was provided through any center or institute at PurdueUniversity. Please attach an additional copy of this page if necessary.

When completed, submit to the:

Office of Technology Commercialization

Campus Address:Mailing Address:

Building – KPTC Purdue Research Foundation

Department – OTC1281 Win Hentschel Blvd., West Lafayette, IN 47906

I have reviewed this Software/technology with the authors/creators and am familiar with the circumstances of its development. I have read the attached information, and specifically confirm to the best of my knowledge the veracity of the assertion set forth above and in the Certificate of Originality. Further, I represent that to the best of my knowledge, the distribution of the Software under an open source license will not (i) violate any legal obligations of or to the University, (ii) limit appropriate University uses of the materials, (iii) create a real or potential conflict of interest for the authors/creators, or (iv) otherwise conflict with University goals or principles.

Approved By:

Center Director / Signature / Date

Comments:

Executive Director, DiscoveryPark / Signature / Date

Comments:

Department Head / Signature / Date

Comments:

Dean of School / Signature / Date

Comments:

Title of the Software(and listing of components, including user's guide viewer's notes etc.)

In your opinion, does the software embody any patentable concepts? Yes No

Date of final draft or working copy of Software:

Date: Reference/Comments:

Is this Software solely the work of PurdueUniversity employees?Yes No

IF there are non-Purdue authors/creators, please contact our office for further direction.

Was the Software reviewed with the Vice President for Research - University Research Administration and Compliance) and a determination made on any concerns with the export control regulations?

Yes No

IF THE ANSWER TO EITHER QUESTION IS “NO,” PLEASE CONTACT OTC FOR ASSISTANCE WITH THIS FORM.

A.Description of Software:The authors/creators must complete and sign a copy of the attached Certificate of Originality (COO), including a detailed description of the Software, and forward the these with this form.

PLEASE LIST ALL PURDUE AUTHORS/CREATORS:

Title / *Name / Dept. / Bldg/Office / E-mail

If necessary, add additional sheets to list all inventors/authors.

B.The undersigned know(s) of no commitment, such as to an industrial or government sponsor or to any additional person or entity that would inhibit Purdue’s ability to carry out its responsibilities under Purdue policies or to third parties if the Software is made available under an open source license.

PLEASE PROVIDE THE FOLLOWING INFORMATION:

Sponsorship Sources (if any):

Purdue facilities/equipment utilized:

Purdue Funds:

Other Funds:

The undersigned authors/creators request(s) that PurdueUniversity agree to make the Software available under the terms of the standard Open Source License below (or alternate license template if requested and approved). The authors/creators represent that open source distribution is in the best interests of PurdueUniversity and their own professional development, and that they believethe Sofware does not have significant commercial value which may best be exploited by the University itself through commercialization of the materials through alicense or similar agreement with an outside party.The authors/creators acknowledge they understand that under the terms of this open source license, commercial entities may adopt and commercialize products based on the Software without further permission from, or compensation to, any individual creator, and without any further permission from, or compensation to, PurdueUniversity.

REQUEST AN ALTERNATE TEMPLATE LICENSE BY CHECKING HERE. (include a copy of the template license if you have a specific license model you would like to use, i.e., GNU Lesser GPL

Open Source License Terms:

Developed by: <Name of Development Group>, <Name of College/Center, PurdueUniversity

Permission is hereby granted, free of charge, to any person obtaining a copy of this software and associated documentation files (the "Software"), to deal with the Software without restriction, including without limitation the rights to use, copy, modify, merge, publish, distribute, sublicense, and/or sell copies of the Software, and to permit persons to whom the Software is furnished to do so, subject to the following conditions:

Redistributions of source code must retain the above copyright notice, this list of conditions and the following disclaimers.
Redistributions in binary form must reproduce the above copyright notice, this list of conditions and the following disclaimers in the documentation and/or other materials provided with the distribution.
Neither the names of <Name of Development Group, Name of Institution>, nor the names of its contributors may be used to endorse or promote products derived from this Software without specific prior written permission.

THE SOFTWARE IS PROVIDED "AS IS", WITHOUT WARRANTY OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO THE WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE AND NONINFRINGEMENT. IN NO EVENT SHALL THE CONTRIBUTORS OR COPYRIGHT HOLDERS BE LIABLE FOR ANY CLAIM, DAMAGES OR OTHER LIABILITY, WHETHER IN AN ACTION OF CONTRACT, TORT OR OTHERWISE, ARISING FROM, OUT OF OR IN CONNECTION WITH THE SOFTWARE OR THE USE OR OTHER DEALINGS WITH THE SOFTWARE.

D.Author/Creator Signatures: The undersigned agree that, if this request is granted, the authors/creators will be responsible for making appropriate arrangements for such distribution, and will ensure thatit is accomplished under the terms indicated in Section C. In addition, the undersigned understand that if this Software is updated or otherwise further developed by any of the undersigned making significant use of Purdue-administered funds or facilities, Purdue may assert further rights in accordance with Purdue policies.

Signature: ______Date: ______

Name (print): ______

Title: ______

Address: ______

Phone: ______

Signature: ______Date: ______

Name (print): ______

Title: ______

Address: ______

Phone: ______

Signature: ______Date: ______

Name (print): ______

Title: ______

Address: ______

Phone: ______

Signature: ______Date: ______

Name (print): ______

Title: ______

Address: ______

Phone: ______

Signature: ______Date: ______

Name (print): ______

Title: ______

Address: ______

Phone: ______

Disclosure form Request for Open Source Distribution 09_09_09_AE.doc

CERTIFICATE OF ORIGINALITY FOR OPEN SOURCE REQUEST

This Certificate of Originality must be completed by authors/creators when making a request for open source distribution of software material which is owned by PurdueUniversity under the provisions of Executive Memorandum B-10, Policy on Intellectual Property

Please leave no questions blank. Write "not applicable" or "N/A" if a question is not relevant to the furnished software material.

1.Name of the Software (provide complete identification, including version, release and modification numbers for programs and documentation):

PLEASE INCLUDE AS AN ATTACHMENT TO THIS FORM A FULL DESCRIPTION OF THE SOFTWARE.

2.Was the software material, or any portion of it, written by any party other than you, or other PurdueUniversity employees working within their job assignment? Yes No If Yes, provide the following information:

Please include in an attachment a description of the contribution made by any third party (indicate if the whole of the software material or only a portion was written by such party) and identify such portion along with contact information for each party. Be sure to address the following:

(i)If the party is a company, how did it acquire title to the software material (e.g., software material was written by company's employees as part of their job assignment)?

(ii)If the party is an individual, did s/he create the software material while under contractual relationship with PurdueUniversity?Yes No

If Yes, please provide a copy of the relevent contract.

If No, provide name and address of the other party and explain the nature of the relationship, and describe the circumstances related to the creation of the software material contribution by the individual:

3.Was the software material or any portion thereof derived from any third party's pre-existing material(s)? This includes any software code adopted under the terms of an existing open source license or otherwise considered by the authors/creators to be available in the public domain.

Yes No If Yes, provide the following information for each of the pre-existing materials:

(a)Name of the materials:

(b)Owner:

(c)How did you get the right to use the pre-existing material (s)?

4.Identify below, any other circumstances which might affect Purdue Universitys ability to reproduce and distribute this software code, including:

Yes No (a)Confidentiality or trade secrecy of pre-existing materials, or .any known or possible licenses to propietary software or any royalty obligations to others.

Yes No (b)Pre-existing material developed for another party (including government) where you may not have retained full rights to the material.

Yes No (c)Materials acquired from a person or company possibly not having title to them.

Yes No (d)Other circumstances:

Please describe any of the above circumstances in an attachment, including a copy of any relevent agreement such as a purchase order, existing contracts or other agreements.

Disclosure form Request for Open Source Distribution 09_09_09_AE.doc

CERTIFICATE OF ORIGINALITY FOR OPEN SOURCE REQUEST

Except as otherwise explicitly described herein regarding use of third party created or owned copyright protected materials, the undersigned authors/creators/submitters warrant(s) with respect to the Software as follows:

that he, she, or they, as the case may be is/are the sole creator(s) of the content or materials I/We provided or contributed to the Sofware, and/or that all materials or other contributions to such in the Software have been made been made or provided by Purdue University employee(s), acting within the scope of employment with Purdue University and/or by Purdue University employees or others subject to a written contract such that the Software would be considered a work-for-hire or an institutional work under the provisions of Executive Memorandum B-10; and
that the Software materials have not heretofore been published or distributed in any form (or if published, the publication date, and publication information, is set forth at the bottom of this Agreement together with all relevant copyright data) and that to the best of the undersigned creator/submitters’ knowledge such materials contain no defamatory matter, invade no person's right of privacy, or include no unlawful matter of any kind; and
that except as explicitly listed or described herein, I/We further warrant and represent that I /We know of no copyrighted material owned by another party or individual that is contained in the Software, and that, as creator or submitter, I/We warrant and represent to Purdue and any party to which Purdue may grant rights to the Software, that the Software is original work of the undersigned and/or solely the work of Purdue University employees not explicitly set forth below, and that it does not infringe any third party owned copyright, and
that, to the extent that such materials made by me are works-for-hire or an institutional work for Purdue University according to the provisions of Executive Memorandum B-10, I/We acknowledge Purdue University as the sole owner of such materials. Further, to the extent materials contributed by me to the Software are not works-for-hire for the University or institutional works, by signing this document I/We hereby assign any rights, including copyrights, I/We may have to the Purdue University, and acknowledge Purdue University as the sole owner of the materials., and
that I/We have authority to enter into this agreement and make the grant of rights contained herein.