Emory Intellectual Property Disclosure Form - Office Of Technology Page 2
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47. Public Disclosure (accurate data is essential as prior disclosure may
Date
References/Comments
affect the possibility of obtaining patent rights)
Please include names of periodicals/journals
(use separate sheet if necessary)
A. First publication containing sufficient description to enable a person skilled
in this field to understand and to make or use the Intellectual Property
(Please include the date submitted or publication date, if published)
B. First public oral disclosure of Intellectual Property sufficient to enable a
person skilled in this field to understand and to make or use the invention
(include slides and/or presentation materials)
C. If this Intellectual Property is unpublished and undisclosed, provide the
anticipated publication or oral disclosure date and any submissions made for
potential publication.
D. Other publications and/or public oral disclosures that provide background
information to this Intellectual Property
E. First sale or public use of Intellectual Property
Yes
No
8. Has the Intellectual Property been reduced to practice?
9. Please attach list of any commercial entities that may be interested in this Intellectual Property (provide as much detail as possible)
10. This Intellectual Property was disclosed to and understood by:
Signature of Non-Inventor Personnel Witness
Date
Name and Title of Witness (please type or print)
I (we) hereby declare that all statements made herein of my own knowledge are true and that all statements made on information and belief
are believed to be true.
Pursuant to the Emory University Intellectual Property Policy, I (We) hereby confirm the assignment of all of my (our) right, title and interest to
this Intellectual Property to Emory University and agree to execute all documents as requested, to assign to Emory University all of my (our)
rights to any patent application filed on this Intellectual Property, and to cooperate with the Emory University Office of Technology Transfer in
the protection of this Intellectual Property. Emory University will share income derived from the Intellectual Property with the inventor(s)
according to its standard policies.
Contributor’s Signature (Emory Personnel)
Date
Contributor’s Signature (Emory Personnel)
Date
Campus Address
Campus Address
Campus Phone
Campus Email Address
Campus Phone
Campus Email Address
Home Address
City, State, Zip
Home Address
City, State Zip
Country of Citizenship
Country of Citizenship
Page 2 of 4
Revised 04/10/2013
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