Invention Disclosure Form

Commercialization Processes

Please complete the following question.

INTELLECTUAL PROPERTY REPORT FORM

What is the title of your innovation?:

Who contributed to this Intellectual Property?

Please list any individuals who made a material contribution, as well as their affiliation (i.e. Birck, Bindley, ARS, IDI, CERIAS, etc). If they are a non-Purdue employee, please provide appropriate contact information. (*see at the end of the form for additional space if more than two contributors)

Name:

Affiliation(s):

Email:

Home Address:

Country of Citizenship:

Name:

Affiliation(s):

Email:

Home Address:

Country of Citizenship:

Describe the IP:

Please provide a technical description of what the IP is and how it works. If you have a manuscript, research proposal, grant, etc. describing the IP please include a copy, even if it is a preliminary draft.

Please describe a useful application of the IP (what problem does the IP solve?):

How does the IP differ than what others are currently doing in your area?:

Has anyone in your group previously described your invention in a journal article or presentation? If so, to whom and when?:

Are you planning to publish/present this IP in the future? If so, when?:

Is there external support for the work leading to this invention (NSF, DOE, DOD, Hatch, corporate, etc.)? If so, what is the entity, grant number, termination date?

Do you have external funding?:

Yes we have external funding or support (details below)

No we do not have external funding

Other...

Entity:

Contract / Grant Number:

Title:

Termination Date:

I provided the above information, which is accurate to the best of my knowledge. (signature below)

Signature:

Signature Date:

Upon successful submission of this report, OTC will contact our to arrange a meeting.

Additional Contributors:

how did you hear about OTC?:

I found you on google

from a newspaper

Office of Technology Commercialization

Purdue Research Foundation

Purdue Research Park

Office of Technology Commercialization

Related Content

Connect with Us

Invention Disclosure Form

Commercialization Processes

INTELLECTUAL PROPERTY REPORT FORM