ࡱ> mohijkl  bjbj 4\++X---8e-=fu. """"!$*Ts-w<y<y<y<y<y<y<B?Aby</!$!$//y<""h=:::/X""w<:/w<:::"@\-w/:c<=0=:FB4FB::JFB;T//://///y<y<:///=////FB///////// :  HYPERLINK "http://www.azte.com/"  Invention Disclosure Form PRIVILEGED AND CONFIDENTIALAzTE Use OnlyTech ID:  FORMTEXT      Date Received:  FORMTEXT      Director of Intellectual Assets:  FORMDROPDOWN Title of the Invention: (should be brief and descriptive)  FORMTEXT      Is the disclosure of this invention regulated by ANY U.S. export laws and regulations pertaining to the export of technical data, services and commodities [i.e. International Traffic in Arms Regulations (ITAR) and/or Export Administration Regulations (EAR)]?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoPotential Inventor(s): (subject to legal review) Please use additional copies of this page for more than four namesFull Name FORMTEXT      Position FORMTEXT      Department(s) FORMTEXT      Center(s) FORMTEXT      University Mail Code FORMTEXT      Telephone FORMTEXT      Email Address FORMTEXT      Country of Citizenship FORMTEXT      Residential Address FORMTEXT      City, State, Zip FORMTEXT      Full Name FORMTEXT      Position FORMTEXT      Department(s) FORMTEXT      Center(s) FORMTEXT      University Mail Code FORMTEXT      Telephone FORMTEXT      Email Address FORMTEXT      Country of Citizenship FORMTEXT      Residential Address FORMTEXT      City, State, Zip FORMTEXT      Full Name FORMTEXT      Position FORMTEXT      Department(s) FORMTEXT      Center(s) FORMTEXT      University Mail Code FORMTEXT      Telephone FORMTEXT      Email Address FORMTEXT      Country of Citizenship FORMTEXT      Residential Address FORMTEXT      City, State, Zip FORMTEXT      Full Name FORMTEXT      Position FORMTEXT      Department(s) FORMTEXT      Center(s) FORMTEXT      University Mail Code FORMTEXT      Telephone FORMTEXT      Email Address FORMTEXT      Country of Citizenship FORMTEXT      Residential Address FORMTEXT      City, State, Zip FORMTEXT      Which of the above should be the primary contact for correspondence?  FORMTEXT      University Lab(s)/resources used to develop this technology: FORMTEXT      Are all inventors listed above employees, officers or students of Arizona State University?  FORMCHECKBOX  Yes  FORMCHECKBOX  No (If No, provide details) FORMTEXT      Are any inventors listed above undergraduate students? FORMCHECKBOX  Yes  FORMCHECKBOX  NoWas any material or equipment provided by a third party?  FORMCHECKBOX  Yes  FORMCHECKBOX  No (If Yes, provide details) FORMTEXT       Federal Grant/Contract or Subcontract FundingWas the invention conceived or first actually reduced to practice in the performance of work funded, in whole or in part, by any federal grant(s), contract(s) or subcontract(s)? (If yes, list below) FORMCHECKBOX  Yes  FORMCHECKBOX  NoSponsor(s):Grant/Contract Number(s):Principal Investigator:ORSPA Account Number(s): FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Certain publications, public disclosures and other activities can adversely affect patent rights. Publication, Public Disclosure & Other Activities:Has the invention been described in any publication(s) (including abstracts)? FORMCHECKBOX  Yes  FORMCHECKBOX  No Name of Publication, journal or website:  FORMTEXT      Date of each publication: FORMTEXT      Has a manuscript describing the invention been submitted for publication?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, has it been accepted for publication at this time? FORMCHECKBOX  Yes  FORMCHECKBOX  NoHas a description of the invention appeared online (including conferences and abstracts)? FORMCHECKBOX  Yes  FORMCHECKBOX  NoWas a grant application describing the invention submitted for review? FORMCHECKBOX  Yes  FORMCHECKBOX  NoWas the invention disclosed publicly, such as in a poster session, presentation or lecture? FORMCHECKBOX  Yes  FORMCHECKBOX  NoWas the invention or any derivative product sold, offered for sale, or used in public? FORMCHECKBOX  Yes  FORMCHECKBOX  NoAre any of the above disclosures or activities contemplated in the near future? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes to ANY of the above, please provide details:  FORMTEXT      If the answer to any of the above questions is YES, please provide detailed information and attach any grants, abstracts, manuscripts, articles, presentations, etc. Please keep our office informed of any future submission or acceptance for publication or other possible disclosure of any manuscripts, abstracts or oral presentations describing the invention. Conception/Disclosure: Conception is defined as: the act of forming a general idea or notion Please fill in the following dates:Conception of discovery: FORMTEXT      First disclosure to another: FORMTEXT      First experiment demonstrating discovery: FORMTEXT      If the discovery or a significant aspect of the discovery is not supported by written records, briefly describe how the date of discovery can be established and identify earliest written record:  FORMTEXT       Type of Invention: (Check all that apply) FORMCHECKBOX  Agriculture/Animal Science FORMCHECKBOX  Environmental FORMCHECKBOX  Medical Devices & Imaging FORMCHECKBOX  Bio-Technology FORMCHECKBOX  Fuel Cells & Energy FORMCHECKBOX  Networks, I/T, Software & Communication FORMCHECKBOX  Drug Screening FORMCHECKBOX  Materials & Electronics FORMCHECKBOX  Therapeutics FORMCHECKBOX  Educational FORMCHECKBOX  Mechanical/ManufacturingOther: (please specify)  FORMTEXT       Abstract/Brief Summary of the Invention: Give an overview of the invention s concept and chief objective(s) or purpose(s). FORMTEXT       Introduction/Background of the Invention: Give context to the invention. 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CJaJph3jKhEhh="UUhEhl6CJaJ hEhl5B* CJaJph3hl jhEhlUmHnHuj"hEhh="UjhEhh="U hEhg hEhg5B* CJaJph3hEhg6CJaJ hEhl3383 $Ifgdlskd$$Ifl *+ t0644 lap ytE83:3<33 $Ifgdl$a$gdJlkd$$Ifl*+ t0644 laytE33| $Ifgdlykd$$Ifl *+  t K0644 lap KytEto which the invention pertains and the developments that led to the invention. FORMTEXT       Detailed Description of the Invention:Give a thorough description of the invention as well as how it is made/executed and used. The description should be so detailed that a person skilled in the field would be able to make and use the invention as a result of reading it. Please be as clear, exact and thorough as possible in your description, and please be sure to clearly identify which element of your research is  the invention.  FORMTEXT       Figures and Descriptions:If you wish to submit documents, presentations, figures, charts or other supporting materials, please list them here and include them with this disclosure. FORMTEXT       Non-Confidential Summary of the Invention:This should be one to two paragraphs in length and should not contain any proprietary information. The non-confidential summary should include an overview of the invention and its impact/commercial potential and may be shared with companies interested in licensing the rights to the invention. FORMTEXT       Novel Aspects of the Invention:Specifically identify those properties of the invention (or the process by which it is made or used) that are novel and that distinguish it from existing technologies. FORMTEXT       Advantages Over Current Technology and Impact:Please identify the invention s advantages over existing alternative products, processes or services. FORMTEXT       Which Companies or Investors are most likely to be interested in this invention?CompanyContactPhoneEmail Address FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Commercial Potential:Please describe the invention s commercial potential, in terms of potential products and services, and describe its competition/available alternatives. FORMTEXT       Related Publications:Please list any papers, patents and other published material that you are currently aware of that either relate to your invention or describe similar technology. Please include links and/or submit copies of the publications when possible. (add supplemental sheet if necessary) FORMTEXT       Certification and Acknowledgement: (please use additional copies of this page if more signatures are required)I certify that the information contained in this Invention Disclosure Form is true, accurate and complete. I acknowledge and agree that the Arizona Board of Regents (ABOR) on behalf of ASU owns the discovery and intellectual property disclosed herein pursuant to HYPERLINK "http://www.azregents.edu/1_the_regents/policymanual/chap6/6-908.pdf"ABOR Intellectual Property Policy #6-908. I hereby assign all rights in the invention disclosed herein to ABOR on behalf of Arizona State University. I understand that Arizona Technology Enterprises (AzTE) is the intellectual property management organization for ASU. If AzTE determines to seek patent or other appropriate protection for the technology described herein, I shall cooperate with AzTE in its efforts to do so and shall sign such documents as may be required for this purpose, including but not limited to an assignment of the discovery to ABOR in a form that may be recorded, a declaration as to inventorship, and power of attorney. I understand that ASU will adhere to the terms of ABOR policy #6-908, as amended from time to time, and will distribute any proceeds from licensing or assigning the technology in accordance with such policy and HYPERLINK "http://www.asu.edu/aad/manuals/rsp/rsp604.html"ASU RSP #604. If it is determined that I am an inventor, I acknowledge that AzTE will need my contact information to facilitate the prosecution and commercialization of this invention. I agree to promptly provide AzTE with any changes to my contact information. My failure to provide current contact information may affect AzTE s ability to prosecute and/or commercialize this invention and my ability to share in any commercialization revenue.SignaturesDate FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Submit the completed form via email to  HYPERLINK "mailto:ip@azte.com" ip@azte.com or via fax to (480) 884-1984. Please call (480) 884-1996 if you have any questions. 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