4. Invention conception and reduction to practice icon

4. Invention conception and reduction to practice



TTO office use only Date Received ID number

CONFIDENTIAL ______________ _______________


Invention Disclosure Form


If you have any questions in filling out this form, please call (303) 384-2555


1. Working Title of the Invention:







2. Description of invention: On a separate sheet of paper, please describe the invention in enough details so that the work is reproducible by someone in the same discipline. This information could include, but is not limited to: draft papers, drawing, photographs, tables, presentations, abstracts, formula, data, prototype description and illustrations.


3. Abstract: Please describe the invention in a non-confidential abstract that can be used as a basis for marketing the technology to potential licensees. This should include advantages of the invention over current solutions to the problem that the invention solves and the commercial applications of the invention. However, do not reveal inventive properties that would allow others to replicate your invention.






^ 4. Invention conception and reduction to practice: Provide the information regarding the conception of the invention. The conception occurs where ordinary skill is required to reduce it to practice. The existing record is most likely the research notebook where the idea is recorded. Reduction to practice means that the first construction and successful operation of the invention.


Date:

Place:

Existing record:

Reduced to practice: Yes No


If Yes:

Date:

Place:

Existing Record:

Witnesses:


5. Disclosure: Please list any disclosure of the inventive elements of the invention to people outside of the Colorado School of Mines. This includes public disclosures, especially printed publications, which can limit the period for filing a US patent application and possibly preclude foreign patents altogether.


How disclosed

To Whom

Date

Place


















































6. Funding Source and Relative Contribution of Each Source:

 

Agency or Company
^

Grant Number


% Contribution





































 

7. Prior Art: List the all art that you are aware of that relates to the invention. These can be reference from a paper in progress, patents or other papers that relate to the invention. Attach copies of these or additional information as needed.


1.

2.

3.


^ 8. Commercial application: Describe the problem the invention solves, the products envisioned, markets in which it could be used and advantages over existing technologies.






^ 9. Known competitive products





10. Potential licensees: List companies and organizations that might be particularly interested in the invention or that are doing similar research. Attach additional information as needed.






^ 11. Conflict of Interest Information


a) Do any of the disclosing parties serve as a director, officer, or board member of the company or companies named above? If so, please list in what capacity each person serves.


Yes No


b) Do any of the disclosing parties work for, or consult for any of these companies? If so, please list the company(s)


.

Yes No


c) Do any of the disclosing parties hold a financial interest (stock options, consulting fees, honorariums or other compensation)? If so, please list the companies and the type of financial interest


Yes No


^ 12. Outside source of material


  1. Was material obtained from outside Colorado School of Mines to create this invention?

Yes No


  1. If Yes, was the material covered by a Material Transfer Agreement or a similar agreement?

Yes No


Material: ____________________________________________

Source: ____________________________________________

Date: ____________________________________________


^ 13. Other comments: Please include any additional information which will help in evaluating and commercializing this invention.







^ 14. Contributors and Revenue Sharing: If more than one inventor involved, Colorado School of Mines policy allows for alternative revenue sharing agreements between potential inventors and contributors. You should discuss the percent distributions among yourselves. All potential inventors and contributors must agree to the revenue distribution arrangements as evidenced by signatures on this page. Inventors other than CSM employees must be noted as such. If left blank, the revenue will be shared equally among the inventors. Please put the lead inventor first.

  

 

Name

Position

Affiliation

Percentage

















































 


Under United States patent law, an inventor is one who has contributed to at least one claim of the patent. The final determination of who is an inventor will be made by Colorado School of Mines’ patent counsel applying the legal standard for inventorship.

Please find attached contact information forms for both Colorado School of Mines inventors and outside inventors. Make as many copies of these as needed and have one for each inventor and have them sign the bottom of the page. Send copies to:


Email: wvaughan@mines.edu


Mail: Office of Technology Transfer

1500 Illinois Street

Guggenheim Hall, Room 306a

Golden, CO 80401


Fax: (303) 273-3244


If you have any questions, please use the above email or call (303) 384-2555

^ Colorado School of Mines inventor contact information


Title:

Last Name:

First Name:

Middle name or initial:

Citizenship:

If not US citizen, please indicate visa type:

Job title:

Department:

Campus Room and Building:

Campus Phone:

Campus Fax:

Email:


Residential Address:


Residential City:

Residential Sate:

Residential Zip Code:

Residential Phone:


Chair:


Please sign and date below, indicating that:

  1. Agreement with the stated percentage of revenues received from the invention, as per the Colorado School of Mines handbook and;

  2. Certification that all the information provided in this disclosure is complete and accurate to the best of your knowledge



Printed Name: _____________________________________


Signature: _____________________________________


Date: _____________________________________

^ Non -Colorado School of Mines inventor contact information


Title:

Last Name:

First Name:

Middle name or initial:

Citizenship:

If not US citizen, please indicate visa type:

Job title:

Institution or Company Name:

Work Address:


Work Phone:

Work Fax:

Email:


Residential Address:


Residential City:

Residential Sate:

Residential Zip Code:

Residential Phone:


Please sign and date below, indicating that:

  1. Agreement with the stated percentage of revenues received from the invention, as per the Colorado School of Mines handbook and;

  2. Certification that all the information provided in this disclosure is complete and accurate to the best of your knowledge



Printed Name: _____________________________________


Signature: _____________________________________


Date: ____________________________________

FORWARD TO: Office of Technology Transfer, 1500 Illinois Street, Guggenheim Hall, Room 306a, Golden, CO 80401




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